MALARIA: How Hidden Can Malaria Be in Pregnant Women?

How Hidden Can Malaria Be in Pregnant Women? Diagnosis by Microscopy, Placental Histology, Polymerase Chain Reaction and Detection of Histidine-Rich Protein 2 in Plasma
Alfredo Mayor et al.
Correspondence: Alfredo Mayor, PhD, Barcelona Centre for International Health Research, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 08036 Barcelona, Spain (agmayor@clinic.ub.es).

Background. Accurate diagnosis of malaria infection during pregnancy remains challenging because of low parasite densities and placental sequestration of Plasmodium falciparum. The performance of different methods to detect P. falciparum in pregnancy and the clinical relevance of undetected infections were evaluated.

Methods. P. falciparum infections were assessed in 272 Mozambican women at delivery by microscopy, placental histology, quantitative polymerase chain reaction (qPCR) and detection of histidine-rich protein 2 (HRP2) in plasma by enzyme-linked immunosorbent assay (ELISA) and a rapid diagnostic test (RDT). Association between infection and delivery outcomes was determined.

Results. Among the 122 women qPCR-positive for P. falciparum in peripheral and/or placental blood samples, 87 (71.3%) did not receive a positive diagnosis by peripheral microscopy, 75 (61.5%) by HRP2 ELISA, and 74 (60.7%) by HRP2 RDT in plasma. Fifty-seven of the 98 qPCR-positive placental infections (58.2%) were not detected by histology. Women who were qPCR-positive but negative in their peripheral blood by microscopy or HRP2 RDT in plasma (n = 62) were at increased risk of anemia, compared with negative women (n = 141; odds ratio, 2.03; 95% confidence interval, 1.07–3.83; P = .029).

Conclusions. Microscopy, placental histology and HRP2-based plasma diagnostic methods fail to identify the majority of the P. falciparum infections detected by qPCR in peripheral and placental blood. Undetected infections were associated with maternal anemia, highlighting the urgent need for more accurate malaria diagnostic tools for pregnant women to avoid the negative clinical impact that hidden infections can have during pregnancy.
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cis236.abstract

MALARIA: Malaria parasites use camouflage to trick immune defences of pregnant women

Researchers from Rigshospitalet – Copenhagen University Hospital – and the University of Copenhagen have discovered why malaria parasites are able to hide from the immune defences of expectant mothers, allowing the parasite to attack the placenta. The discovery is an important part of the efforts researchers are making to understand this frequently fatal disease and to develop a vaccine. Staff member at CMP. Photo: Lars Hviid"We have found one likely explanation for the length of time it takes for the expectant mother's immune defences to discover the infection in the placenta," says Lea Barfod, MSc, who is working with Professor Lars Hviid at the Centre for Medical Parasitology, University of Copenhagen.
"The parasites are able to assume a camouflage that prevents their recognition by the immune system antibodies which would otherwise combat them. So although the immune system has all the weapons it needs to fight the infection of the placenta, these weapons are ineffectual simply because the enemy is hard to spot. Ironically the camouflage also consists of antibodies, but of a type that does not help to fight infection."
The malaria parasite at war with the immune system
One human being in twelve is infected with malaria. That means 500 million people are carrying the tiny parasite, and it kills a million of them a year. The disease costs so many lives because the parasite constantly outmanoeuvres the human immune system. It starts by hiding in the red blood cells. The immune system does not bother with these as the spleen usually filters defective blood cells.
To avoid this filter, the parasite ejects a protein hook which attaches to the inner wall of the blood vessel, and even if the immune system antibodies destroy one such hook, the parasite has more than sixty in its arsenal. One of them has evolved specially to attach to the placenta. While the war is being waged the parasite propagates and infects more and more red blood cells, which are normally used for transporting nutrients and oxygen around the body.

Fighting from house to house
"In an advanced version of hide-and-seek the parasites keep looking for new ways of preventing the antibodies from recognising them. It is a kind of urban guerrilla war in which the fighting is conducted from house to house," says Lars Hviid.
"One example is the ability of the parasites to hide in the placenta. The first time an African woman conceives her placenta provides a new opportunity for the parasite to hide: a new house, so to speak, and in a way that prevents discovery by the immune system. It takes time for the immune defences to react to the new threat, and meanwhile the camouflaged parasite harms the woman and her unborn child."
The researchers are now going to study whether the malaria parasite also uses its camouflage at other stages of an infection.
"Perhaps it is not only the parasites in the placenta that are capable of hiding like this," Lars Hviid says.
"It takes the body a surprisingly long time to develop protection from Malaria, and perhaps the trick we have just discovered is part of the explanation. It is important for us to find out if this is the case in order to help us to understand malaria in general, but also to help us in our efforts to develop a vaccination. We have plenty of work to be going on with," Lars Hviid concludes.

###

Lea Barfod and Lars Hviid's discovery has just been published in the Proceedings of the National Academy of Sciences of the United States of America.

Contact: Professor Lars Hviid : lhviid@sund.ku.dk 452-274-7426 University of Copenhagen

MALARIA: Intermittent Preventive Treatment with Sulfadoxine-Pyrimethamine against Malaria and Anemia in Pregnant Women

Nana O. Wilson*, Fatou K. Ceesay, Samuel A. Obed, Andrew A. Adjei, Richard K. Gyasi, Patricia Rodney, Yassa Ndjakani, Winston A. Anderson, Naomi W. Lucchi and Jonathan K. Stiles
Abstract.
The effectiveness of intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) against malaria and anemia is unclear because of the spread of SP-resistant Plasmodium falciparum. This study evaluates the effectiveness of IPTp-SP among pregnant women attending the antenatal clinic at Korle-Bu Teaching Hospital in Accra, Ghana. A cross-sectional study comparing malaria and anemia prevalence among pregnant women using IPTp-SP with non-IPTp-SP users was conducted during June–August 2009. A total of 363 pregnant women (202 of IPTp users and 161 non-IPTp users) were recruited. A total of 15.3% of IPTp users had malaria compared with 44.7% of non-IPTp users (P < 0.001). A total of 58.4% of non-IPTp users were anemic compared with 22.8% of IPTp users (P < 0.001). When we controlled for other variables, the difference in the prevalence of malaria (odds ratio = 0.18, 95% confidence interval = 0.08–0.37) and anemia (odds ratio = 0.20, 95% confidence interval = 0.12–0.34) remained significant. The recommended IPTp-SP regimen is useful in preventing malaria and anemia among pregnant women in Ghana.

http://www.ajtmh.org/content/85/1/12.abstract

MALARIA: Family Planning and Malaria

Bill Brieger : 09 Jul 2011
Preparations are underway for the 2011 International Conference on Family Planning in Dakar later this year. Although the date is some months away, the organizers are encouraging potential participants and interested persons to become engaged in online discussion forums. An issue we would like to explore here is whether there is any connection between malaria and family planning.


One positive connection is child survival. Researchers in Ethiopia report that, “Immunization, breastfeeding and low parity mothers were independently found to be protective from childhood death. Strengthening the child survival initiatives, namely universal child immunization, family planning and breast feeding — is strongly recommended.” These characteristics were positively associated with reduced deaths from pneumonia, malaria and diarrhea. Clearly the reduced parity component can be achieved in part through successful family planning.
Connections may come through health systems strengthening. Experiences from the Lao Peoples’ Republic show that, “Synergies of Global Fund support with the health system include improved access to services, institutional strengthening and capacity building …” For example opportunities to enhance community service delivery for malaria could also be used to extend family planning services. Thus, sometimes malaria activities are integrated into successful reproductive health services, and at other times the reverse happens, or one finds malaria, family planning and other services handled under one roof as seen in Senegal or eastern Burma.
A great concern is that malaria is dangerous in pregnancy. Any way to space pregnancies or limit the number of times women face the risk of malaria in pregnancy, can save mothers from malaria deaths directly or indirectly from malaria-induced anemia. We encourage dialogue among all partners in maternal and reproductive health and malaria control leading up to the November conference.
http://www.malariafreefuture.org/blog/?p=1240#comment-266895

MALARIA: The changing face of malaria in maternal health

Bill Brieger : 18 Jun 2011
Jhpiego organized a panel attended by over 80 people at the just concluded Global Health Council annual conference entitled, “The changing face of malaria in maternal health,” moderated by Bill Brieger and coordinated by Aimee Dickerson. The overlap between high malaria prevalence and high maternal mortality in Africa was stressed. Although both are generally decreasing, the pace of change is quite slow for meeting Millennium Development Goals and malaria elimination targets. The time of neglecting malaria in pregnancy (MIP) should be over.

As efforts increase toward malaria elimination and the epidemiology of malaria changes, we need to be prepared at the country and global levels. This was illustrated through four presentations that focused on …
Nigeria, a high burden country, needs to consider ways to scale up
Rwanda, a country closing in on elimination, needs to more carefully define and target MIP transmission
New interventions developed through research and Rolling out these new interventions through donor support Enobong Ndekhedehe of Community Partners for Development based in Akwa Ibom State Nigeria spoke on community involvement to increase IPTp & ITN coverage in a highly endemic area. This joint project with Jhpiego, sponsored by the ExxonMobil Foundation, showed successfully that community volunteers supported by front-line antenatal clinic staff could greatly increase uptake of intermittent preventive treatment and thus provided a model for scale up in a high burden country.
Corine Karema who heads the National Malaria Control Program in the Rwanda Ministry of Health, addressed the feasibility of determining the prevalence of MIP during ANC in an era of declining incidence. Intense distribution of long lasting insecticide treated nets and wide availability of artemisinin-based combination therapy for malaria treatment at the community level have resulted in a 70% decline in malaria incidence between 2005 & 2010. Good ANC coverage and availability of staff to test pregnant women on their first ANC visit were found to bode well for providing not only an opportunity for pregnancy-specific prevalence determination, but also an opportunity for future interventions based on routing screening and treatment.
Theonest Mutabingwa from the Hubert Kairuki Memorial University, Tanzania talked on “The future MIP research agenda in the context of malaria elimination,” based on the plans and experiences of the Malaria in Pregnancy Consortium (MIPc), of which he is a member. MIPc teams from African and northern research institutes are looking into such issues as the changing role of prevention (e.g. IPTp vs screening and treatment), When is it optimal to change interventions (use of modelling), what are the changing patterns of disease epidemiology and immunity in pregnant women, what are the criteria or thresholds upon which to switch control strategies, what should constitute guidelines to define high/moderate, low and very low transmission settings, among others.
Finally Jon Eric Tongren of the US President’s Malaria Initiative (PMI) provided a donor’s perspective on MIP programming in countries with changing malaria epidemiology. This presentation showed that even with input from multiple donors, MIP intervention targets for IPT and LLIN use are well below the RBM 2010 goal of 80% and the PMI goal of 85% despite demonstrated increases in coverage of both services. Even though effective MIP interventions exist, they need to be strengthened through well-executed assessments, collaborative implementation, and careful follow-up, monitoring, and evaluation. Echoing the research agenda expressed before, the presenter stressed the need for continued surveillance to map progress and change in prevalence and adaptation of MIP strategies as prevalence changes.
MIP control faces a double challenge. Since this component of national malaria control programs has often been neglected, there is a need to catch up and achieve 2010 coverage targets. Then moving forward, strengthened monitoring and surveillance is needed to fine tune, revise and better target MIP interventions to make a bigger impact on reducing maternal mortality in endemic countries.
http://www.malariafreefuture.org/blog/?p=1222

MALARIA: Nigeria: maternal mortality

From: William Brieger
Subject: [malaria] Nigeria - maternal mortality and malaria
To: "Malaria Update"
Date: Thursday, May 19, 2011, 5:09 AM
Maternal deaths still high in Nigeria - Expert •Malaria kills 4,500 pregnant women in Nigeria yearly -Ogun Health Commissioner
Written by Olayinka Olukoya with News AgencyThursday, 19 May 2011
A reproductive health expert, Dr Ejike Oji, says maternal mortality rate is still high in Nigeria and requires urgent attention to check the trend.
Oji is the Country Director of IPAS Nigeria, a non-governmental organisation that protects women's health and advances women's reproductive rights.
He told the News Agency of Nigeria (NAN) in Port Harcourt, on Wednesday, that in spite of efforts made by government and stakeholders, maternal mortality rate was still high in Nigeria.
He said that Nigeria was second to India in maternal deaths in the world.
Meanwhile, Ogun State Commissioner for Health, Dr Isiaq Salako, has disclosed that about 4,500 pregnant women die of malaria in the country annually.
http://tribune.com.ng/index.php/news/22203-maternal-deaths-still-high-in-nigeria-expert-malaria-kills-4500-pregnant-women-in-nigeria-yearly-ogun-health-commissioner

William Brieger
http://www.malariafreefuture.org/blog/
Senior Malaria Specialist, JHPIEGO - http://www.jhpiego.org/whatwedo/malaria.htm
I think very important question has been posed here 'what are being done to reduce these problems?' For Malaria the high impact interventions include 1) use of Long Lasting Insecticide Treated Nets (LLINs), 2) Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp), and 3) effective case management of malaria using appropriate anti-malarial drugs (ACTs). We are aware LLINs have been distributed in most States in Nigeria through local and international efforts and supports, but appropriate usage especially amongst those at risk remains a huge challenge. I am not sure that we will be able to say that those that received the nets are actually using it as prescribed. Furthermore, Malaria in pregnancy (MIP) prevention and control still remains a component of Focus Ante Natal Care (ANC) in our National Guideline while we are quite aware from available research evidence that ANC attendance among pregnant women in most parts of Nigeria remains very low. While there is an on-going efforts to pilot new approach, obviously, a huge number of pregnant women (those that ordinarily will not attend ANC) are missed-out at baseline given the current national MIP guideline. More importantly is the on-going pilot efforts to improve case management of malaria at all levels through the roll out of the 'use of rapid diagnostic test kits for parasitological diagnosis of malaria, dispensing of appropriate anti-malarial drugs (ACTs) and availability of cheap ACTs through the Affordable Medicines Initiative (AmFm) that is expected to crowd-out the use of wrong anti-malarial drugs and high costly ACTs.

However, the delay in rolling out this important initiative across the country is a challenge that may have compromised our on-going efforts. Addressing these challenges affecting each of the high impact interventions using the GFATM and other donor funds most appropriately, scale-up of the interventions and sustainability. On sustainability, our government at all levels must rise up to spend substantially on health. Good enough the National Health Bill has been finally passed, much kudos to those that fought for it but the battle is far from being won. let us remember that we have always had good policies with poor implementations. It is my sincere wish that all hands must be on deck till the battle against malaria is finally won, Hope to see it come to pass in my life time.
Jhpiego - Innovating to Save Lives
Orji Bright
Jhpiego - An Affiliate of Johns Hopkins University, Baltimore 2/6 Akpakpan Street, CPD BuildingUyo, Akwa Ibom State. Nigeria Country Office, 3rd Floor, Labour House, Central Area, Garki.
Mobile: +234 80 370 96014
Email Address: oclement@jhpiego.net
Website Address: www.jhpiego.org


From: Emmanuel Otolorin eotolorin@jhpiego.net
To: Malaria Update
Sent: Sat, May 21, 2011 2:06:47 PM
Subject: [malaria] RE: Nigeria - maternal mortality and malaria

The Nigeria 2008 NDHS showed Nigeria’s Maternal Mortality Ratio (MMR) to be 545 deaths per 100,000. That translates to 33,000 maternal deaths every year. Since we know that malaria is responsible for 11% of these deaths, we can therefore estimate that malaria kills 3630 pregnant women every year which is not too different from what was reported in the news below. I think it’s better for us to begin to ask questions about what is being done to reduce this problem. We should thank the Global Funds for AIDS, TB and Malaria (GFATM) for its very generous grant of over $500m to tackle the problem of malaria in Nigeria. Other donors who have supported Nigeria include the World Bank, DfID, USAID, ExxonMobil etc. The Nigerian government, through the MDG office, has also chipped in. We just need to see that the interventions being implemented (use of insecticide treated bed-nets, intermittent preventive treatment with Sulphadoxine-Pyrimethamine and case management with an Artemisinin-Combination Therapy (ACT) are sustained sufficiently over a long period to ensure a satisfactory impact.


From: Ali Gambo [mailto:aigambo2003@yahoo.com]  Friday, May 20, 2011 10:57 AM
To: Malaria Update Subject: [malaria] Nigeria - maternal mortality and malaria
The statistics is quite shocking, to say the least. But I do hope somebody is not playing politics with Statistics. Come to think of it, whose responsibility is it?
Inundating the public with such shocking Statistics will not serve the purpose of gingering people into action.
What happened to the "roll malaria back" plans and campaigns after the launching fanfare?
Ali.I.Gambo (Applied Statistician)
....Education is our passport to the future, for tomorrow belongs to those who prepare for it.......Malcolm X.

MALARIA: Nigeria: Maternal deaths still high

19 May 2011 : Olayinka Olukoya
Maternal deaths still high in Nigeria - Expert •Malaria kills 4,500 pregnant women in Nigeria yearly -Ogun Health Commissioner

A reproductive health expert, Dr Ejike Oji, says maternal mortality rate is still high in Nigeria and requires urgent attention to check the trend.
Oji is the Country Director of IPAS Nigeria, a non-governmental organisation that protects women's health and advances women's reproductive rights.
He told the News Agency of Nigeria (NAN) in Port Harcourt, on Wednesday, that in spite of efforts made by government and stakeholders, maternal mortality rate was still high in Nigeria.
He said that Nigeria was second to India in maternal deaths in the world.
“If you look at the maternal mortality rate, which is an indicator of maternal health in any country, a few years ago, our maternal mortality was one thousand one hundred.
“But the last check has now put it at 545 maternal deaths for every hundred thousands live births.
“But you can see that 545 is still huge, is still very, very high when you compare it to some countries who have maternal mortality of about five, four.
“And that means , it is translating to about fifty something thousand women dying annually in Nigeria.
“That is a lot of women dying. In fact, Nigeria contributes second largest maternal deaths in the world after India.
“And you know, India is 1.2 billion and we are just about 152 million. So, India is 10 times our size and we are second to them in terms of total maternal deaths in the world,” he said.
Meanwhile, Ogun State Commissioner for Health, Dr Isiaq Salako, has disclosed that about 4,500 pregnant women die of malaria in the country annually.
Salako spoke during a symposium to commemorate this year’s World Malaria Day, which took place in Abeokuta, the Ogun State capital, on Wednesday.
Describing malaria as a major public health problem which ravages Nigeria’s population, the commissioner lamented that the scourge affects the growth and development of the country.
He also estimated that 50 per cent of the population had at least one episode of malaria each year while children below five years of age had two to four attacks of malaria each year.
Malaria, he stressed, remains a great threat to the survival of the young African children, accounting for 30 per cent of all childhood deaths.
The commissioner, who addressed participants at the symposium, stated that the major burden of diseases in the African region, including Nigeria, is attributable to vector-borne diseases.
He said: “The disease malaria is no respecter of age, sex or tribe. People of all ages have regular attacks throughout their lives.
“However, young children and pregnant women are most at risk of severe malaria and death.
‘’Malaria also contributes to other children deaths by affecting immunity to other diseases. Successful malaria control measures could therefore result in a large reduction of deaths more than that due to malaria alone.”
‘’We must all be concerned in malaria in pregnancy, whether we are still within the child-bearing age or not. It is our responsibilities to make sure that we do everything humanly possible to prevent and control the menace of malaria in our society.
‘’For us in Ogun State, we believe that prevention is better than cure. It is not only better to prevent malaria, but it is also cheaper. He urged pregnant women not to hesitate to always go for ante-natal.
According to him, it was estimated that 80 per cent to 90 per cent of global clinical malaria cases (300 million) and malaria-related deaths (one million) occur on the African continent in Nigeria.
He added that about 40 per cent of the population of the world is at risk and about 300 to 500 million cases occur globally every year.
http://tribune.com.ng/index.php/news/22203-maternal-deaths-still-high-in-nigeria-expert-malaria-kills-4500-pregnant-women-in-nigeria-yearly-ogun-health-commissioner

MALARIA: Zambia: Door-to-door bednet distribution

Cecilia Katebe, Zambia National Malaria Control Centre Zambia uses community volunteers to help hang millions of bednets in homes to improve utilization rates.
Zambia’s National Malaria Control Programme (NMCP) is expected to distribute over 5 million nets in 2011, of which approximately three-quarters shall be distributed using the door-to-door distribution strategy in an effort to increase the usage of the nets being distributed. The remaining quarter will be distributed to pregnant women and children under five years of age through antenatal clinics. A high percentage of people in Zambia own bednets because of the government’s ongoing efforts to scale up the distribution of malaria control interventions, which, in addition to bednets, include indoor residual spraying and effective medicines. Though 64.3 percent of households own at least one bednet, the 2010 Malaria Indicator Survey (MIS) determined that only 42 percent of people were actually using the nets. The NMCC conducted a survey and found that there were a number of reasons for the low utilization rates. Many people said that they weren’t using the nets because they didn’t know how to hang them or they didn’t have the accessories to hang them; others said that they only use the bednets in the rainy season when mosquitoes are very visible.
The door-to-door campaign was launched in 2009 as a means of increasing utilization rates. During the campaign, Community Health Workers, Neighborhood Health Committee members, and other trained volunteers take the nets right up to individual houses and ensure the nets are hung properly before leaving the household. This also provides an opportunity to share important messages on malaria prevention and control.
In November 2009, a door-to-door distribution pilot was conducted in Chongwe District of Lusaka Province and a follow-up survey found that about 93 percent of households that had received nets during the pilot were using those nets. Based on these excellent results, it was decided that the door-to-door distribution strategy would be used to distribute the all the nets received in 2011.
During this year’s mass distribution, one volunteer will be responsible for 20 households in a village and, whenever possible, a volunteer will be chosen that also lives in the village and is a member of the community. This is really useful for several different reasons: the family will already know and trust the volunteer, they will be more likely to be honest about how many nets they need, and they will be more likely to allow them into their bedroom to help hang their nets. There is a high demand for bednets, but the challenge is being allowed into a bedroom to help hang a net. To address this issue, we’ve engaged traditional leaders to help people understand why this is important. The volunteers will then collect the data and bring it to the health center, where it is consolidated and used to determine how many nets a district needs. When the nets arrive, the volunteers will go back to the houses and distribute the nets, helping to hang them in each sleeping space in a household. To do this sort of distribution requires a massive effort with many people participating, so training is key.
Each volunteer visits the same house several times throughout the year. During their first visit, they note the number of sleeping spaces, how many people live in each house, and how many existing nets they have. An ITN database at the central level details all the nets that have been delivered to every district, the type of nets, the program under which the nets were distributed, and the month when the nets were received. This information is used for planning purposes and can produce a forecast that reveals areas of critical need.
Trainings for the upcoming distribution are started when it’s known that a shipment of nets is coming. Districts in need are then identified and a meeting with local stakeholders—including malaria task force committees, ministries, nongovernmental organizations, churches, and local leaders—is arranged. It is important to make sure the district office, with the support of the local partners, is able to handle the storage, distribution, and information-sharing once the nets are received. Health center staff, neighborhood health committees, relevant trainers, and door-to-door distribution volunteers are then trained. Through a strong partnership, coordinating body, and dedicated volunteers, millions of nets will be distributed this year and the work to protect Zambians from malaria will continue.
Door-to-door mass distribution is just one of the ways nets are distributed in Zambia. They are also distributed under the Malaria in Pregnancy Programme through antenatal clinics to pregnant women and children under age five, the Equity Programme to vulnerable populations like the elderly and the chronically ill by NGOs through the MOH, and through the World Bank-supported Community Malaria Booster Response programme.
http://www.macepalearningcommunity.org/newsletter_bednets.htm

MALARIA: Malarone in pregnancy

Amy Norton : Feb 16, 2011
NEW YORK (Reuters Health) - Pregnant women who take the anti-malarial drug Malarone during their first trimester might not be increasing their baby's risk of birth defects, a new study suggests.
Most anti-malaria drugs -- including this one -- are not approved for use in pregnancy. So when pregnant women want to travel to malaria-ridden regions, they face a huge problem: should they take preventive medicines that haven't been proven safe for the fetus?
In general, experts advise all pregnant women to avoid traveling to countries where malaria is common, since the infection itself may be dangerous to the mother and fetus.
The new study, published in the Archives of Internal Medicine, is the first to look at pregnant women's use of Malarone -- known generically as atovaquone-proguanil -- and the risk of birth defects.
So the researchers say it is too soon to declare the drug safe for the small number of pregnant women who might need to take it.
The cheapest and mostly widely used anti-malaria drug, called chloroquine, is considered safe during pregnancy. But resistance to that drug has become common worldwide.
Another anti-malaria drug, the antibiotic doxycycline, is known to have adverse effects on the fetus.
In the new study, researchers looked at data on nearly 571,000 births in Denmark between 2000 and 2008. Overall, 2 to 3 out of every 100 newborns had a birth defect.
Among the 149 women who used Malarone at some point during the first trimester, roughly one of every hundred had a baby with a birth defect.
The findings offer some reassurance that the drug is not linked to any large risk of birth defects, said lead researcher Dr. Bjorn Pasternak, of Statens Serum Institute in Copenhagen.
Still, since only a small number of women in the study took Malarone during early pregnancy, the findings cannot rule out the possibility of some risk, Pasternak said.
"We believe it is far too soon to declare this drug to be safe for use in pregnancy," he told Reuters Health in an email.
Malarone is not inexpensive -- it costs close to $200 for 24 pills. The number of pills a woman would have to take depends on how long she stays in the malaria region.
Caused by a mosquito-borne parasite, malaria is widespread (the technical term is "endemic") in large areas of Africa, Asia and South and Central America, where it kills about 1 million people a year.
An estimated 10,000 to 30,000 travelers develop malaria every year, and about 150 die.
http://www.reuters.com/article/2011/02/16/us-malaria-drug-idUSTRE71F66K20110216?feedType=RSS&feedName=healthNews

MALARIA: Methods To Protect Pregnant Women From Malaria Are Still Underutilised In Sub-Saharan Africa

26 Jan 2011
A study published in The Lancet Infectious Diseases finds that methods to protect pregnant women from malaria are still underutilised in sub-Saharan Africa (SSA). A review of national control strategies by a team of international researchers, led by the Malaria in Pregnancy Consortium and funded by the Consortium and the Wellcome Trust, has concluded that despite major efforts, coverage is still inadequate in many areas and needs to be scaled up.

Malaria infection in pregnancy can lead to devastating consequences for both mother and child. The World Health Organization's (WHO) recommended policy for malaria prevention and control is a package of intermittent preventive treatment (IPTp) and insecticide treated nets (ITNs). These interventions have the potential to substantially reduce the disease burden and adverse outcomes of malaria in pregnancy. The Roll Back Malaria initiative (RBM) has ambitions to ensure that 100% of pregnant women receive IPTp and at least 80% of people at risk from malaria are using ITNs in areas of high transmission by 2010.
Specific strategies for malaria control in pregnant women were extracted from national malaria policies and the most recent national household cluster-sample surveys recording IPTp and ITN use were reconciled to sub-national administrative units to compute the numbers of protected pregnancies. Malaria maps generated by the Malaria Atlas Project (MAP, www.map.ox.ac.uk) meant these estimates could be stratified against different levels of malaria risk.
The study found that 45 of 47 SSA countries had an ITN policy for pregnant women and that estimated coverage was 17% among the nearly 28 million pregnancies at risk of malaria in the 32 countries with information. Among 39 countries with an IPTp policy, 25% of pregnant women had received some IPTp, despite 77% visiting an antenatal clinic (ANC), the main delivery channel for reaching pregnant women with ITNs and IPTp.
Professor Feiko ter Kuile, MiP Consortium leader and co author said: "Ten years after the Abuja declaration, it is encouraging that the majority of malaria endemic countries in SSA have now adopted ITNs and IPTp and the number of countries with nationally representative coverage data has increased to 40 out of 47. However, very few countries have reached either the Abuja targets or their own policy ambition, and countries are even further away from the more recent RBM targets set for 2010. In addition, coverage was lowest in areas with high malaria transmission, where the need is greatest.
"In general, low coverage with IPTp and ITNs contrasts with correspondingly high ANC attendance, indicating that there are missed opportunities for coverage and the attainment and maintenance of high coverage of ITNs remains challenging.
"In summary, whilst most countries have adopted national policies aimed at reducing and controlling malaria in pregnancy, it is clear that, with some notable exceptions, not enough progress has been made towards the new RBM goals or the policy ambitions of each country.
"With only five years in which to meet the Millennium Development Goals it is sobering that in countries with a national policy for IPT and/or ITN, an estimated 23 million pregnancies remain unprotected by an ITN and 19 million remain unprotected by IPTp. Greater effort to fully understand the reasons why coverage is so low and to develop strategies to combat this is urgently needed to protect the tens of millions of pregnancies in sub-Saharan Africa threatened by malaria every year."
http://www.medicalnewstoday.com/articles/214767.php

MALARIA: Ghana: Use of Mosquito Nets Still Low Says Research Findings

Phyllis D. Osabutey: 20 January 2011
The Behaviour Change Support (BHS) Project, together with its partners, Water and Sanitation Hygiene (WASH) and Focus Region Health Project (FRHP), has disseminated the findings of their baseline survey concerning various aspects of health delivery, towards improving service in the sector.
The findings, which covered critical issues on malaria, water, sanitation and hygiene, family planning (FP), maternal, infant and child health, and health systems among others, were carried out in the Greater Accra, Central and Western, Volta and Eastern regions.
Among other things, the research aimed at establishing socio-economic and demographic characteristics of target households, identify the behaviour change communication needs, especially, concerning WASH, and assess the health care delivery and systems currently in place to inform programme interventions.
The three organisations, which are also partners of the United States Agency for International Development (USAID), made the findings known to stakeholders in health service delivery and members of the media in Accra on Friday.
The Senior Monitoring and Evaluation (M&E) Specialist of BCS, Mr. Joseph Sineka Limange, touching on malaria, said their finding indicated that the use of mosquito nets was still quite low, and that there was no meaningful difference in use by both sexes, as only 23.6% of the study population slept under any mosquito nets the previous night, while 17.4% slept under the Long Lasting Insecticide Net (LLIN).
On the other hand, 26.4% of pregnant women, who were sampled, slept under any type of net the previous day, while 22.1% slept under LLIN, and 35.5% and 27.9% of children under five slept under any type of net and LLIN respectively, the previous night.
On the whole, 41.2% and 35.6% of under fives in the Western Region slept under any type of net and LLIN respectively, while those for the Central Region was 39.6% and 27.7% respectively, and that for Greater Accra 29.5% and 17.8% respectively.
Also, there was a difference in use by rural and urban dwellers, which translated as 27.6% and 20.0% for any type of net and LLIN respectively, with that of urban being 48.0% and 36.3% respectively.
According to Mr. Limange, "Men seem to encourage their children to sleep under nets more than women," because, "while 62.4% of men indicated that their children slept under nets, only 59.1% of women indicated likewise."
The reasons for non-usage of mosquito nets by children, as indicated by the adult respondents, included the belief that it was too hot, the nets were worn out, nets not hung up, there were not enough nets, and no nets at all.
The respondents also believed the causes of malaria included mosquito bites, dirty areas/stagnant water, eating dirty food and drinking dirty water, while they perceived malaria as a threat to life, because it could prevent people from working and earning money, and slow a child's growth among others.
The M&E Specialist of Relief International, Mr. Saaka Adams, who touched on the WASH findings, said they sought to find out how to solve the problem of access to potable water, low patronage of water facilities at the rural level, and sustainability of water facilities among others.
According to him, the aim was to maximise the health impact for people through the use of potable water and other health facilities like toilets, and hygienic habits like washing of hands in the study areas.
In terms of access to water, he indicated that 32% of the respondents had access to potable water all year round in an improved water facility within 500 meters walking distance, with the Greater Accra Region having the highest rate of 39.7%.
On the other hand, 68% do not have access to potable water all year round, and used unimproved sources of water, usually from sources far from households.
Mr. Adams explained that transporting water from such sources to households often resulted in contamination, especially, because people often put in leaves or rubber into open containers used to carry water, so as to stabilise the water and avoid pouring.
He continued that while 97.5% of households stored water, 18% of them treated their water through methods such as boiling, use of alum and camphor, filtering, and other methods that are not entirely safe.
On access to sanitation, he observed that households used water closets, traditional pit latrines, Kumasi Improved Improved Pits (KVIPs) among others, adding that "21.5% of households have access to effective sanitation, with the regional access in the Western Region being 34.8%, and 10% for the Central Region."
He lamented that open defecation was still prevalent, constituting 66.7% in the Central Region, and defecation along the beaches entrenched in Teshie, because there were fewer sanitation facilities to serve the increasing number of people in the area.
He noted that there was also the practice of export, by which means people defecated into rubbers and containers to drop into gutters among others, while there was also shared use of latrines by more than one household of about 57% in the Central and 43.7% in the Western regions.
The M&E Specialist further stated that the study revealed that the disposal of baby feaces was often done by means of dumping in the bush (49%), rinsed into toilets (22%), refuse dump (17%), burying (9%), and left in the open (4%).
He gave physically challenged persons access to sanitation facilities as 45% in the open, 24% in the household, 14% in chamber pots and 17% in traditional pit latrines, with the major problem to them being the long distance they had to walk before accessing sanitation facilities.
The M&E Specialist of FRHP, Elizabeth Hammah, on her part, said their study identified gaps and areas of service provision that need strengthening, such as the need to ensure supportive supervision of health data management at facility level.

http://allafrica.com/stories/201101200682.html

MALARIA: Impact of Malaria at the End of Pregnancy on Infant Mortality and Morbidity

Azucena Bardají1, et al. : Barcelona Centre for International Health Research and Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomèdicas August Pi i Sunyer, Universitat de Barcelona, Spain (abardaji@clinic.ub.es).

Background. There is some consensus that malaria in pregnancy may negatively affect infant's mortality and malaria morbidity, but there is less evidence concerning the factors involved.
Methods. A total of 1030 Mozambican pregnant women were enrolled in a randomized, placebo-controlled trial of intermittent preventive treatment with sulfadoxine-pyrimethamine, and their infants were followed up throughout infancy. Overall mortality and malaria morbidity rates were recorded. The association of maternal and fetal risk factors with infant mortality and malaria morbidity was assessed.
Results. There were 58 infant deaths among 997 live-born infants. The risk of dying during infancy was increased among infants born to women with acute placental infection (odds ratio [OR], 5.08 [95% confidence interval (CI), 1.77–14.53)], parasitemia in cord blood (OR, 19.31 [95% CI, 4.44–84.02]), low birth weight (OR, 2.82 [95% CI, 1.27–6.28]) or prematurity (OR, 3.19 [95% CI, 1.14–8.95]). Infants born to women who had clinical malaria during pregnancy (OR, 1.96 [95% CI, 1.13–3.41]) or acute placental infection (OR, 4.63 [95% CI, 2.10–10.24]) had an increased risk of clinical malaria during infancy.
Conclusions.  Malaria infection at the end of pregnancy and maternal clinical malaria negatively impact survival and malaria morbidity in infancy. Effective clinical management and prevention of malaria in pregnancy may improve infant's health and survival.

MALARIA: The impact of maternal malaria on newborns.

Hartman TK, Rogerson SJ, Fischer PR.:  Ann Trop Paediatr. 2010;30(4):271-82.
BACKGROUND: Each year, malaria threatens 125 million pregnancies, and gestational malaria is responsible for up to 200,000 infant deaths in sub-Saharan Africa. With advancing knowledge of malaria in pregnancy and its impact on newborns, improved preventive and therapeutic interventions are possible.

METHODS: We reviewed and, by consensus, evaluated published literature relevant to malaria and newborns. Important findings are summarised.

RESULTS: Pregnant women are more likely than others to be inoculated with and infected by malaria parasites. Poor outcomes are particularly common in primigravid women and their offspring. The placenta is affected through cellular adhesion, cytokine production and mononuclear cell infiltrates. As a result, newborns may have low birthweight owing to intrauterine growth retardation or prematurity. Recent evidence suggests that a subset of these infants is also at higher risk of malaria infections later in life. Preventive strategies to improve maternal and fetal outcomes include intermittent preventive treatment and insecticide-treated bed nets. Asymptomatic malaria infection is not uncommon in newborns, and symptomatic disease occurs. Fever and death are possible during the early days of life, and presentation with a sepsis-like illness can occur during the 1st 2 months of life. Malaria-affected infants face higher than usual risks of infantile anaemia, subsequent malaria infection and death during the 1st year of life.

CONCLUSIONS: Malaria is common during pregnancy and can have serious consequences for neonatal health. Neonatal morbidity and mortality can be significantly reduced by proper implementation of insecticide-treated nets and intermittent preventive treatment.
http://www.ncbi.nlm.nih.gov/pubmed/21118620

MALARIA: Large-Scale Malaria Treatment in the Private Sector:

EXECUTIVE SUMMARY
Population Services International/Cambodia (PSI/Cambodia) was established in 1993 to address child survival (safe water and diarrhea treatment), HIV/AIDS, malaria, and reproductive health needs among women of child-bearing age, caretakers of children under five, and high-risk groups including commercial sex workers and men who have sex with men. Following a successful pilot in 2002, in 2003 PSI/ Cambodia established an initiative to provide branded malaria treatment through private clinics, pharmacies, and shops across most of rural Cambodia. By 2009 this program provided half of all malaria treatment in the country and 75% of all artesunate and mefloquine (AS/MQ) distributed.1 Cambodia was the first country to pilot and then scale-up the provision of subsidized ACTs in the private sector.

The PSI/Cambodia malaria program sells a branded version of the same ACT supported by Cambodia’s National Malaria Control Program, known as “CNM.” PSI/Cambodia imports the ACTs directly into its Phnom Penh warehouse before distributing them to three regional PSI depots. PSI-employed sales representatives make monthly sales calls to 1,737 private outlets. 500 of these are clinicianor pharmacy-operated facilities that are also visited once per month by PSIemployed medical detailers who provide training, counseling, and support on the appropriate use of ACTs, malaria test kits, and other medicines.

Stock outs have been a major problem for the program since inception. The primary causes of stock outs have been changes in the approval status of manufacturers, and long procurement timelines often associated with donor delays which have hindered the arrival of ACTs into Cambodia. Because of PSI/Cambodia’s
in-house management of the in-country supply chain, no stock outs have been reported resulting from breakdowns of the supply chain within Cambodia; breaks have all been the result of delays in the procurement of Malarine into Cambodia and affect both the public and private sector’s ability to deliver.

ACTs sold through the PSI/Cambodia program are highly subsidized, and are sold to private outlets at an average price of $0.29,2 with a recommended average price to-patients of $0.45.3 In practice, the price of Malarine to patients has been documented to vary considerably, ranging between $0.82 and $1.18.4 This price volatility and overcharging appears to be due primarily to fluctuations in the supply of ACTs.
http://www.globalhealthsciences.ucsf.edu/pdf/GHG-Cambodia-Case-Study.pdf

MALARIA: Malaria in Pregnancy & Procurement Supply Management

 Bill Brieger : 14 Dec 2010
Michelle Wallon from Jhpiego’s Zambia office discusses the challenges of maintaining stocks of sulphadoxine-pyrimethamine (SP) for use in Intermittent Preventive Treatment for pregnant women (IPTp) that arose during recent Roll Back Malaria meetings in Livingstone and Lusaka:



The effects of malaria in pregnancy are many and the interventions, simple. Intermittent Preventive Treatment (IPTp), insecticide-treated bed nets, and timely case management can reduce effects including maternal anemia, low birth weight, and maternal and fetal mortality. Yet, when speaking to clinicians and public health experts across Africa about prevention and control of malaria in pregnancy (MIP), there is a common theme – stock-outs of SP, the drug used for IPTp, commonly inhibit the effectiveness of MIP interventions.
IPTp is relatively straight-forward and SP, is an inexpensive drug. Furthermore, at the time that the IPTp recommendations were adopted via the Abuja Declaration in 2000, many countries were still procuring SP as the first-line treatment for the general population (For example, Nigeria did not officially switch to ACTs as firstline malaria drugs until 2005).
SP supplies were abundant when it was still recommended as treatment. What then is the problem now?
Although SP stock-outs are formally documented in only a few African countries, including Zambia, Tanzania, and Malawi, the problem can be inferred by most of the recent Demographic and Health Survey and Malaria Indicator Survey reports (e.g. Liberia, Nigeria, Uganda, Senegal) showing low coverage of the recommended two doses of IPTp. MIP experts readily and repeatedly identify a handful of culprits for the SP stock-out phenomenon.
One set of problems surrounds continued and irrational use of SP for treatment in RDT-negative cases in the general population that siphon off SP supplies from MIP services. These stem from …
Provider mistrust of RDTs coupled with policies that ACTs be provided only after positive diagnosis via RDT or microscopy
Real or perceived high incidences of malaria
Strong correlation in the community between fever and malaria with high expectations for malaria treatment
Weak clinical skills in the appropriate diagnosis and management of fever
Lack of skilled providers and high client loads
Inaccurate SP quantification based on population rather than consumption data and/or quantification failing to account for irrational use also create stock problems. Weak logistics systems with bottlenecks between central-level drug stores and receiving facilities result in stock-outs of both SP and ACTs.
These problems are not new and neither are the solutions. MIP has a potential advantage in that it falls under both reproductive health and national malaria control programs, and yet the persistence of SP stock-outs indicates that this is often used less as an opportunity for collaboration than as an excuse to pass the buck.
As the public health community moves towards more integrated programming, we must seize the opportunity to bridge the programmatic gap.
http://www.malariafreefuture.org/blog/?p=1116