Category Archives: Malaria in Pregnancy

Mentorship to Strengthen Quality of Malaria Case Management & Malaria in Pregnancy, Zimbabwe

Gilson Mandigo et al. examine how mentoring can be achieved from a distance in Zimbabwe. Their presentation at the 69th Annual Meeting of American Society of Tropical Medicine and Hygiene of “Mentorship to Strengthen Quality of Malaria Case Management And Malaria in Pregnancy (MIP) in Zimbabwe: Lessons Learned From One Year of Implementation” is shared below.

Despite significant investment in training and supervision of facility-based health workers in Zimbabwe, persistent malaria case management and MIP gaps remain. National Malaria Control Program and US President’s Malaria Initiative developed and implemented a mentorship intervention in five high burden malaria districts to motivate provider performance and improve quality services.

From June 2018 – June 2019, 25 health workers proficient in malaria service delivery were selected and trained in clinical mentorship. These individuals mentored 98 providers at 25 facilities, covering clinical case reviews, bedside coaching, simulations, and records review. USAID’s Zimbabwe Assistance Project in Malaria subsequently assessed the mentorship program through review of patient records, feedback from mentors and mentees, and engagement of stakeholders.

Record review compared practices before and after implementation, using a checklist that noted completeness and appropriateness of case management across multiple parameters, including physical examination, diagnosis, classification and treatment. Mentored facilities documented improvements in recommended practices across registers: 58% to 63% for outpatient clinical settings, 53% to 64% for integrated management of neonatal and childhood illnesses, and 72% to 76% for antenatal care.

A phone-based e-survey of 49 mentees and 21 mentors elicited positive feedback on the mentorship approach: 62% of mentors were “very satisfied” with the program, 67% reported quality improvement and 86% benefited from learning new skills. Among mentees:

  • 60% were “very satisfied”,
  • 67% said that the program has improved service quality and
  • 97% benefited from learning new skills

Common challenges included mentor transportation, mentee availability, and commodity availability. Through a review meeting, stakeholders recommended the intervention continue, as it was acceptable, feasible and achieved promising results. Recommendations include prioritizing high-volume facilities, integrating management of mentorship into District Health Executive functions and use of low-cost communication platforms to aid virtual mentorship.

Authors and Affiliations

Gilson Mandigo(1), Anthony Chisada(1), Noe Rakotondrajaona(2), Paul Matsvimbo(3), Christie Billingsley(4), Chantelle Allen(5), Katherine Wolf(5), Patience Dhliwayo(3). 1.ZAPIM/Jhpiego, Harare, Zimbabwe, 2.ZAPIM/Abt, Harare, Zimbabwe, 3.MOHCC, Harare, Zimbabwe, 4.PMI, Harare, Zimbabwe, 5.Jhpiego HQ, Baltimore, MD, United States

Group Antenatal Care to Improve Malaria in Pregnancy & ANC in Geita, Tanzania

Jasmine Chadewa and colleagues are sharing their work on Group Antenatal Care (GANC): A Baseline Initiative to Improve Malaria in Pregnancy & ANC Indicators. A Case from Geita Tanzania at the virtual 69th Annual Meeting of American Society of Tropical Medicine and Hygiene. See their findings below.

Malaria in pregnancy (MiP) is a major public health concern contributing to poor maternal and newborn health outcomes. Early and frequent Antenatal Care attendance (ANC) could address this problem. Early ANC booking is still low in Tanzania. USAID Boresha Afya and Tanzania Ministry of Health introduced a Group Antenatal Care (GANC) initiative in Geita region where malaria prevalence is high. This model brings 8-15 pregnant women of similar gestational age together for ANC. Group contacts last 1.5-2 hours, and include clinical care, information sharing, and peer support to improve quality of care and women’s engagement, leading to better retention in care.

Prior to implementation, a baseline cross-sectional household survey was conducted in December 2019 in 40 communities across Geita region. The survey was intended to identify gaps and targets in MiP services delivery which could be addressed through GANC. Women who had delivered a live born infant in the preceding 12 months were included. We interviewed 1111 women; mean age was 27 years. One-third had no education and only 9% had secondary education.

Nearly all 95% of women lived in a house with an Insecticide Treated Net (ITN); 87% reported receiving an ITN during their last pregnancy and 90% reported ITN use on the night before the survey. Nearly all 98% attended ANC at least once, with 17% attending in first trimester. Only 45% attended ?4 visits; 6% of women were stopped by their husbands from attending ANC.

Median total time spent away from the home for each ANC was 4 hours. 88% received Intermittent Preventive Treatment of malaria in pregnancy (IPTp), with 53% receiving the recommended 3 or more doses. Among those who did not receive IPTp, 42% reported that the provider did not offer it and 25% reported it was not available at the facility. Receipt of other interventions varied: 64% reported that their blood pressure was checked, 95% and 57% had blood and urine samples collected, 74% had received adequate doses of tetanus vaccination, and 94% received iron/folate supplements.

We will assess whether GANC improves MiP services as well as quality of ANC care, to promote positive pregnancy outcomes.

Authors and Affiliations

Jasmine Chadewa1, Mary Drake1, Chonge Kitojo2, Ryan Lash3, Stephanie Suhowatsky4, Abdalah Lusasi5, Japhet Simeo6, Goodluck Tesha7, Ruth Lemwayi1, Issa Garimo5, Agnes Kosia1, Alice Christensen1, Rita Noronha1, Zahra Mkomwa7, Naomi Serbantez2, Melkior Assenga1, Erik Reaves8, Samwel Lazaro5, Miriam Kombe9, Alen Kinyina1, Alen Kinyina1, Ally Mohamed5, Gladys Tetteh4, Bill Brieger10, Edward Kenyi4, Annette Almeida1, Julie Gutman3
1USAID Boresha Afya Project -Jhpiego Tanzania, Dar es Salaam, Tanzania, United Republic of, 2President’s Malaria Initiative/United States Agency for International Development, Tanzania, Dar es Salaam, Tanzania, United Republic of, 3Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Dar es Salaam, Tanzania, United Republic of, 4Jhpiego Headquarter U.S.A, Baltimore, MD, United States, 5National Malaria Control Program-Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania, United Republic of, 6Regional Health Management Team, Dar es Salaam, Tanzania, United Republic of, 7USAID Boresha Afya Project –Path Tanzania, Dar es Salaam, Tanzania, United Republic of, 8President’s Malaria Initiative, Centers for Disease Control and Prevention Tanzania, Dar es Salaam, Tanzania, United Republic of, 9USAID, Dares Salaam, Dar es Salaam, Tanzania, United Republic of, 10Jhpiego Headquarter U.S.A, Dar es Salaam, Tanzania, United Republic of

What could hinder IPTp uptake?

Cristina Enguita-Fernàndez and colleagues share findings on from a qualitative study on the acceptability of a community-based approach to IPTp delivery in 4 sub-Saharan countries in the UNITAID TiPTop project. Their poster is available at the vitrual 69th Annual Meeting of American Society of Tropical Medicine and Hygiene.

Increasing uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is key to improving maternal health indicators in malaria endemic countries, yet current coverage rates remain low. This qualitative study is part of a project evaluating the acceptability of a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in 4 countries: the Democratic Republic of Congo (DRC), Madagascar, Mozambique and Nigeria.

Between March 2018 and February 2020 a total of 435 in-depth interviews and 181 focus group discussions were carried out in the four country sites with pregnant women, relatives, women of reproductive age, community leaders, CHWs, and health providers. These were combined with direct observations of both community and facility based IPTp delivery.

Grounded theory guided the study design and data collection, and data were analysed following a combination of content and thematic analysis to identify barriers to IPTp uptake. Although the novel C-IPTp intervention overcomes some access barriers (such as distance from health care providers, and travel costs), the study identified important barriers, some of which cut across delivery mechanisms and others that are specific to the C-IPTp approach.

Cross-cutting barriers consisted of perceived attributes of SP that explain treatment refusal. These consisted of sensorial characteristics, including the drug’s perceived foul smell, taste and large size; experiences with adverse drug effects, such as nausea and weakness; fears of adverse pregnancy outcomes, such as miscarriages or oversized babies leading to C-sections.

Attributes originated either in individual experiences of SP intake or were socially transmitted. Barriers specific to C-IPTp were centered around concerns over trust in CHWs as adequate providers of maternal healthcare and their competence in delivering IPTp. Despite sensitization activities, misinformation could still be determining these barriers. Ensuring an improved awareness of SP effects and its use, as well as a better understanding of the intervention should lead to enhanced C-IPTp adherence

Authors and Affiliations

Cristina Enguita-Fernàndez1, Yara Alonso1, Wade Lusengi2, Alain Mayembe2, Aimée M. Rasoamananjaranahary3, Estêvão Mucavele4, Ogonna Nwankwo5, Elaine Roman6, Franco Pagnoni1, Clara Menéndez1, Khátia Munguambe4 – 1ISGlobal – Barcelona Institute for Global Health, Barcelona, Spain, 2Bureau d’Étude et de Gestion de l’Information Statistique, Kinshasa, Congo, Democratic Republic of the, 3Malagasy Associates for Numerical Information and Statistical Analysis, Antananarivo, Madagascar, 4Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique, 5University of Calabar, Calabar, Nigeria, 6Jhpiego, affiliate of Johns Hopkins University, Baltimore, MD, United States

Community health workers’ sex and variation in uptake of malaria in pregnancy services in Ebonyi State, Nigeria

Ebonyi members of Integrated Health Data Management Team (IHDTM) providing mentorship to HCWs during RDQA visit to Akpaka

Bartholomew Odio et al. work with CHWs who promote community delivery of intermittent preventive treatment for pregnant women in Ebonyi State, Nigeria for the UNITAID/Jhpiego TiPToP Project. They shared below some of their findings from the virtual 69th Annual Meeting of American Society of Tropical Medicine and Hygiene this week. (Photos are from Bright Orji)

In Nigeria, malaria remains a high burden disease and pregnant women are among the most vulnerable. According to the 2019, World Malaria Report only 31% of pregnant women received the World Health

CHWs at data validation meeting during COVID 19 pandemic social distancing

Organization recommended minimum of three doses of IPTp with Sulfadoxine-Pyrimethamine (SP) compared to 17% in Nigeria (DHS, 2018). In order to expand the coverage of this life-saving intervention, the Transforming Intermittent Preventive Treatment for Optimal Pregnancy project engaged community health workers (CHWs) to introduce the delivery of community IPTp (C-IPTp) to eligible pregnant women, in addition to women being able to access IPTp at antenatal care in Ohaukwu district of Ebonyi State, Nigeria.

Community meeting in Bosso

As findings from studies in Nepal and Uganda showed that the sex of CHWs were correlated with uptake of iCCM services, we examined routine project data to determine if the sex of the CHWs was correlated with uptake of IPTp. Of the 462 CHWs selected, 49% were male and 51% were female and were deployed at a ratio of one CHW to 27 pregnant women. All CHWs were trained on early identification of pregnant women, referral to antenatal care and provision of C-IPTp using SP.

A trained data analyst extracted routine data from the national community health management information system for 13,733 pregnant women who received IPTp from CHWs between June and November 2019. Data abstracted included CHW sex and number of PW that received IPTp. Findings showed that female CHWs distributed 60% of IPTp1, 65% IPTp2, and 61% IPTp3 (p-value=0.00 for all comparisons). The data suggest that trained female CHWs may reach more pregnant women than their male counterparts in community directed IPTp interventions.

Authors and Affiliations

Bartholomew Odio(1), Onyinye Udenze(1), Chinyere Nwani(1), Herbert Onuoha(1), Elizabeth Njoku(1), Lawrence Nwankwo(2), Oniyire Adetiloye(1), Bright Orji(1) 1.Jhpiego, Nigeria, Abuja, Nigeria, 2.State Ministry of Health, Nigeria, Abuja, Nigeria. This is part of the TiPToP Project funded by UNITAID.

Achieving antenatal care attendance and intermittent preventive treatment in pregnancy in Geita, Tanzania

Ryan Lash and colleagues examined factors associated with achieving antenatal care (ANC) attendance and intermittent preventive treatment in pregnancy (IPTp) and made recommendations in Geita Region, Tanzania, 2019. There findings are being presented at the virtual 69th Annual Meeting of American Society of Tropical Medicine and Hygiene.

Malaria in pregnancy results in an estimated 10,000 maternal and 100,000 infant deaths globally each year. To reduce this burden, the World Health Organization (WHO) recommends pregnant women in high to moderate malaria transmission areas receive at least 3 doses of intermittent preventive treatment in pregnancy (IPTp3) with sulfadoxine-pyrimethamine (SP) starting in the second trimester as part of routine antenatal care (ANC). Tanzania has national coverage goals of 80% coverage for women receiving IPTp3 and at least four ANC visits (ANC4).

We surveyed women 15-49 years who had given birth in the last 12 months from randomly selected households across 40 communities in Geita Region, Tanzania. ANC attendance and IPTp uptake was recorded from respondent ANC cards if available, or self-reported. Predictors of ANC4 and IPT3 uptake were identified using logistic regression modeling, accounting for clustering and controlling for gravidity.

Of 1,111 women surveyed, 505 (51.9%) received IPTp3 and 472 (43.4%) achieved ANC4. Among women who achieved ANC4, 295 (62.5%) received IPTp3. IPTp3 was associated with basic knowledge about ANC and IPTp (aOR 2.4, CI 1.9 -3.1), initiating ANC <20 weeks (aOR 1.7, CI 1.3-2.3), waiting at the facility for <120 minutes (aOR 1.4, CI 1.1-1.9), and receiving advice from a health worker about SP (aOR 1.7, CI 1.3-2.2).

ANC4 was associated with better access to care (aOR 1.9, CI 1.3-2.8, for travelling <3.75 km to ANC and aOR 1.9, CI 1.1-2.2, for waiting <90 minutes for the provider), initiating ANC at <20 weeks gestation (aOR 10.7, CI 8.2-14.1), and basic knowledge about ANC and IPTp (aOR 1.4, CI 1.0-1.9). Poor access to care and late initiation of ANC reduced the likelihood that women will attend 4 ANC visits. Knowledge was a predictor of both ANC attendance and IPTp uptake; increasing women’s health literacy may overcome some of the barriers associated with retention in ANC.

New approaches to delivering ANC that focus on improving knowledge and the experience of care among ANC clients could help close coverage gaps for ANC4 and IPTp3 in Tanzania

Authors and Affiliations

R. Ryan Lash(1), Ruth Lemwayi(2), Melkior Assenga(2), Alen Kinyina(2), Annette Almeida(2), Samwel L. Nhiga(3), Lia Florey(4), Chonge Kitojo(5), Erik Reaves(6), Miriam Kombe(5), Ally Mohamed(3), Japhet Simeo(7), Stephanie Suhowatsky(8), Mary Drake(2), Julie Gutman(1) 1.US Centers for Disease Control and Prevention, Atlanta, GA, United States, 2.Jhpiego Tanzania, Dar es Salaam, Tanzania, United Republic of, 3.National Malaria Control Program, Tanzania, Dar es Salaam, Tanzania, United Republic of, 4.US Agency for International Development, Washington, DC, United States, 5.US President’s Malaria Initiative / US Agency for International Development Tanzania, Dar es Salaam, Tanzania, United Republic of, 6.US Centers for Disease Control and Prevention / US President’s Malaria Initiative Tanzania, Atlanta, GA, United States, 7.Regional Medical Office, Geita, Geita, Tanzania, United Republic of, 8.Jhpiego, Baltimore, MD, United States

Provider Communication about IPTp and ITNs for Pregnant Women in Tanzania

Courtney Emerson and co-workers address the issues of Intermittent Preventive Treatment of Malaria with Sulfadoxine Pyrimethamine and Provision of Insecticide Treated Nets in Geita, Tanzania: Provider Communication and Opportunities at the virtual 69th Annual Meeting of American Society of Tropical Medicine and Hygiene. See their findings below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is a life-saving intervention to reduce morbidity and mortality among pregnant women and their infants. Additionally, provision and use of insecticide treated nets (ITNs) to prevent malaria is critical to improving pregnancy outcomes.

To assess implementation of malaria in pregnancy services and related health communications, we surveyed 1111 women who had delivered a live born infant in the preceding 12 months (recently pregnant women), as well as 1194 adults from randomly selected households without a recently pregnant woman in Geita Region, Tanzania in 2019. Most (88.2%) recently pregnant women reported receiving any IPTp dose; 45.5% received 3 doses. 72.3% of women received their first dose in the second trimester, as recommended by national guidelines, but only 14.4% received IPTp in the 4th month; 20.3% of women did not receive IPTp until third trimester.

There was a significant difference between ITN ownership and use among households (HH) with and without a recent pregnancy: ownership of at least one net was 95.2% vs 87.9%, respectively (p<0.0001), and use was 90% vs 77.8%, respectively (p<.0001). Despite this, few HHs had enough ITNs to cover all residents; on average, HHs had 1 ITN for every 3 rather than every 2 people, as recommended. Notably, only 21.2% and 26.2% of HH with and without a recent pregnancy had sufficient ITNS (p=0.005), despite 87.3% of recently pregnant women receiving an ITN during their last pregnancy.

Of recently pregnant women, 87% received advice on preventing malaria from a health worker. Of these, 82.7% were advised to sleep under an ITN, but only 66.4% were advised to take SP, and 52.1% to attend ANC regularly. Although uptake of any IPTp was high, there are critical messages that need to be more consistently communicated to pregnant women by ANC providers including the importance of attending ANC regularly during pregnancy. To improve outcomes among pregnant women, additional net distribution may be warranted due to the unexpectedly low access.

Authors and Affiliations

Courtney Nicole Emerson(1), Ryan Lash(1), Ruth Lemwayi(2), Melkior Assenga(2), Alen Kinyina(2), Annette Almeida(2), Samwel L. Nhiga(3), Lia Florey(4), Chonge Kitojo(5), Erik Reaves(6), Miriam Kombe(5), Peter Winch(7), Stephanie Suhowatsky(7), Mary Drake(2), Julie Gutman(1) 1.US Centers for Disease Control and Prevention, Atlanta, GA, United States, 2.Jhpiego, Dar es Salaam, United Republic of Tanzania, 3.National Malaria Control Program, Tanzania, Dar es Salaam, United Republic of Tanzania, 4.US Agency for International Development (USAID), Washington DC, DC, United States, 5.US Agency for International Development (USAID), Dar es Salaam, United Republic of Tanzania, 6.US Centers for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania, 7.Jhpiego, Baltimore, MD, United States

 

Scoping Review of the Key Determinants and Indicators of Malaria in Pregnancy, Madagascar (2010-2019)

This year the 69th Annual Meeting of American Society of Tropical Medicine and Hygiene is virtual.  Catherine Dentinger and colleagues (see authors below) gathered information to guide partner planning to combat malaria in pregnancy in Madagascar. Here are their findings.

Malaria in pregnancy (MIP) increases the risk of poor maternal and infant outcomes; to prevent this, the World Health Organization (WHO) recommends insecticide-treated net (ITN) use, intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), and prompt case management. In Madagascar, IPTp uptake remains low; 10% of targeted women receive 3 doses.

To determine if additional data are needed to improve MIP activities, we conducted a scoping review to identify barriers to antenatal care (ANC) and IPTp uptake. We searched PubMed, Google Scholar and USAID’s files (Development Experience Catalog) using the terms “Madagascar” and “pregnancy” and “malaria” and collected materials from stakeholders. We included English and French documents from 2010 to 2019 with quantitative or qualitative data regarding malaria during pregnancy.

Documents were reviewed and categorized as MIP background information, care seeking, and facility readiness. Of 69 project reports, surveys and published articles, 15 (22%) met the inclusion criteria; 4 (27%) were categorized as care seeking, 4 (27%) as background, and 7 (47%) as facility readiness.

Eight (53%) articles mentioned SP stock outs, 3 (20%) mentioned poor provider knowledge of IPTp guidelines despite recent training, and 5 (33%) discussed barriers to ANC including distance, wait times, poor service quality, cost, and unfriendly providers. One study found only 30% of targeted health workers received recommended supervision.  A 2015 survey of 52 health facilities revealed limited access to ANC due to financial and geographic barriers; 2018 surveys revealed similar findings. Self-treatment and care-seeking delays were reported even when distance was not a barrier.

Our review revealed well-documented barriers to MIP services that could be mitigated by reducing stock outs, improving access to healthcare by removing fees and providing services closer to women’s homes, and targeted behavior change. These findings can be used to guide coordinated donor and government efforts to address management, financial, and human resource gaps to improve MIP services.

Authors and Affiliations

Catherine Dentinger(1), Natasha Hansen(2), Susan Youll(2), Annett Cotte(1), Mary Lindsay(3), Chiarella Matten(4), Vololoniala Aimee Ravaoarinosy(5). 1.Centers for Disease Control and Prevention, Atlanta, GA, United States, States, 3.US Agency for International Development, Washington, DC, United States, 4.Institut Pasteur de Madagascar, Antananarivo, Madagascar, 5.National Malaria Control Program, Antananarivo, Madagascar 2.US Agency for International  Development, Washington DC, DC, United States

Malaria News Today 2020-10-26: Haiti, India, Malaysia, Cape Verde

Recent news and abstracts explore malaria on three continents. Genetic aspects of malaria are studied in Haiti as well in Malaysia. Use of fish to control malaria carrying mosquitoes are successful in India. The movement toward malaria elimination is examined in Cape Verde. Finally, Non-invasive diagnostic tests are recognized/rewarded by NIH. Read more by following the links below.

NIH Awards Prize to Hemex Health’s Non-Invasive Sickle Cell, Malaria, Anemia Rapid Test (“SMART”) Diagnostic Technology

Researchers from Hemex Health, Medtronic plc, Case Western Reserve University, and the University of Nebraska Medical Center’s International Foundation Against Infectious Disease in Nigeria (IFAIN) were awarded 3rd place and $100,000 in the NIH Technology Accelerator Challenge.  Code named, SMART (Sickle, Malaria, Anemia, Rapid Test), the system includes non-invasive diagnostics for sickle cell, malaria, and anemia. The project seeks to build on Hemex Health’s Gazelle® platform, which currently includes minimally invasive tests (using a drop of blood) for malaria, the detection and quantification of hemoglobin variants, as well as for total hemoglobin for anemia determination.

The non-invasive test will screen for anemia, malaria, and sickle cell disease using an optical finger sensor similar to the way blood oxygen is measured. An advantage of combining the non-invasive and minimally invasive diagnostics is, when needed, more diagnostic information and confirmation is available on the same platform. The goal is a one-minute, $0.25 non-invasive malaria, sickle cell, and anemia test. “The world desperately needs easy-to-use diagnostic technologies with the flexibility needed to meet viruses and diseases in every corner of the planet,” said Ms. White.

Controlling Mosquitoes: Ramanathapuram district inches closer to malaria-free status

Steps taken by the Ramanathapuram district administration to control mosquito breeding for the last five years has enableed the district inch closer to being declared a ‘malaria-free district, with only one malarial fever case having been reported till September, this year. Last year, the district reported 43 cases.

One of the initiatives is to bring guppy fish from the Ayyankulam tank in Tiruvannamalai district and let them into all wells and tanks of the districts in 3:1 ratio (3 familes/one male). The fish thrives, eating the mosquito larvae and eggs and the incidence of malaria came down in the district.

Updates on malaria epidemiology and profile in Cabo Verde from 2010 to 2019: the goal of elimination

Located in West Africa, Cabo Verde is an archipelago consisting of nine inhabited islands. Malaria has been endemic since the settlement of the islands during the sixteenth century and is poised to achieve malaria elimination in January 2021. The aim of this research is to characterize the trends in malaria cases from 2010 to 2019 in Cabo Verde as the country transitions from endemic transmission to elimination and prevention of reintroduction phases. All confirmed malaria cases reported to the Ministry of Health between 2010 and 2019 were extracted from the passive malaria surveillance system.

A total of 814 incident malaria cases were reported in the country between 2010 and 2019, the majority of which were Plasmodium falciparum. Cabo Verde has made substantial gains in reducing malaria burden in the country over the past decade and are poised to achieve elimination in 2021. However, the high mobility between the islands and continental Africa, where malaria is still highly endemic, means there is a constant risk of malaria reintroduction. Characterization of imported cases provides useful insight for programme and enables better evidence-based decision-making to ensure malaria elimination can be sustained.

Genetic analysis reveals unique characteristics of Plasmodium falciparum parasite populations in Haiti

With increasing interest in eliminating malaria from the Caribbean region, Haiti is one of the two countries on the island of Hispaniola with continued malaria transmission. While the Haitian population remains at risk for malaria, there are a limited number of cases annually, making conventional epidemiological measures such as case incidence and prevalence of potentially limited value for fine-scale resolution of transmission patterns and trends. In this context, genetic signatures may be useful for the identification and characterization of the Plasmodium falciparum parasite population in order to identify foci of transmission, detect outbreaks, and track parasite movement to potentially inform malaria control and elimination strategies.

This study evaluated the genetic signals based on analysis of 21 single-nucleotide polymorphisms (SNPs) from 462 monogenomic (single-genome) P. falciparum DNA samples extracted from dried blood spots collected from malaria-positive patients reporting to health facilities in three southwestern Haitian departments (Nippes, Grand’Anse, and Sud) in 2016.

437 of the 462 samples shared high levels of genetic similarity–at least 20 of 21 SNPS–with at least one other sample in the dataset. These results revealed patterns of relatedness suggestive of the repeated recombination of a limited number of founding parasite types without significant outcrossing. These genetic signals offer clues to the underlying relatedness of parasite populations and may be useful for the identification of the foci of transmission and tracking of parasite movement in Haiti for malaria elimination.

Epidemiology of malaria among pregnant women during their first antenatal clinic visit in the middle belt of Ghana

A total of 1655 pregnant Ghanaian women aged 18 years and above with a gestational age of 13–22 weeks, who attended an antenatal care (ANC) clinic for the first time, were consented and enrolled into the study. A structured questionnaire was used to collect socio-demographic and obstetric data and information on use of malaria preventive measures. Venous blood (2 mL) was collected before sulfadoxine-pyrimethamine administration. Malaria parasitaemia and haemoglobin concentration were determined using microscopy and an automated haematology analyser, respectively.

One out of five pregnant women attending their first ANC clinic visit in an area of perennial malaria transmission in the middle belt of Ghana had Plasmodium falciparum infection. Age???25 years, multigravid, educated to high school level or above, and in household with higher socio-economic status were associated with a lower risk of malaria parasitaemia. Majority of the infections were below 1000 parasites/µL and with associated anaemia. There is a need to strengthen existing malaria prevention strategies to prevent unfavourable maternal and fetal birth outcomes in this population.

Genetic diversity of circumsporozoite protein in Plasmodium knowlesi isolates from Malaysian Borneo and Peninsular Malaysia

Understanding the genetic diversity of candidate genes for malaria vaccines such as circumsporozoite protein (csp) may enhance the development of vaccines for treating Plasmodium knowlesi. Hence, the aim of this study is to investigate the genetic diversity of non-repeat regions of csp in P. knowlesi from Malaysian Borneo and Peninsular Malaysia.
The phylogenetic analysis revealed indistinguishable clusters of P. knowlesi isolates across different geographic regions, including Malaysian Borneo and Peninsular Malaysia.

The csp non-repeat regions are relatively conserved and there is no distinct cluster of P. knowlesi isolates from Malaysian Borneo and Peninsular Malaysia. Distinctive variation data obtained in the C-terminal non-repeat region of csp could be beneficial for the design and development of vaccines to treat P. knowlesi.

Malaria News Today 2020-10-15

Recent publications in Malaria Journal, The Lancet and eLife tackle several challenges to saving lives and malaria elimination. Problems include low access to bednets for children in Ethiopia, high prevalence of asymptomatic malaria in Ghanaian adults, risk of co-infection with other infectious diseases, and gaps in current interventions to prevent malaria in pregnancy and children. On the hopeful side, new targets for drug therapy are being identified. Read more on each by following the links below.

Long-lasting insecticide-treated bed net ownership, utilization and associated factors among school-age children in Southern Ethiopia

Zerihun Zerdo and colleagues examined net use among children in malaria-prone areas of

Dara Mallo and Uba Debretsehay districts because malaria is one of the major causes of morbidity and mortality among school-age children (SAC) in sub-Saharan Africa. This study was part of a baseline assessment in a cluster-randomized controlled trial.

The ownership of at least one LLIN by households of school-aged children (SAC) was about 19.3% (95% CI 17.7–21.0%) but only 10.3% % (95% CI 7.7–13.7%) of these households had adequate access of bed nets to the household members. Ownership of bed net was lower than universal coverage of at least one bed net for two individuals. It is important to monitor replacement needs and educate mothers with low education level with their SAC on the benefit of consistent utilization of bed nets.

Prevalence of and risk factors for Plasmodium spp. co-infection with hepatitis B virus: a systematic review and meta-analysis

Kotepui and Kotepui observed that Plasmodium spp. and hepatitis B virus (HBV) are among the most common infectious diseases in underdeveloped countries. Therefore they examined co-infection in people living in endemic areas of both diseases. The PubMed, Web of Science, and Scopus databases were searched. Observational cross-sectional studies and retrospective studies assessing the prevalence of Plasmodium species and HBV co-infection were examined. and found 22 studies to include in a systematic review and meta-analysis. Overall, the pooled prevalence estimate of Plasmodium spp. and HBV co-infection was 6% (95% CI 4–7%, Cochran’s Q statistic?<?0.001, I2: 95.8%).

No difference in age or gender and risk of Plasmodium spp. and HBV co-infection group was found. The present study revealed the prevalence of Plasmodium spp. and HBV co-infection, which will help in understanding co-infection and designing treatment strategies. Future studies assessing the interaction between Plasmodium spp. and HBV are recommended.

High prevalence of asymptomatic malaria infections in adults, Ashanti Region, Ghana, 2018

Melina Heinemann and co-researchers noted that Ghana is among the high-burden countries for malaria infections and recently reported a notable increase in malaria cases. While asymptomatic parasitaemia is increasingly recognized as a hurdle for malaria elimination, studies on asymptomatic malaria are scarce, and usually focus on children and on non-falciparum species. Therefore asymptomatic adult residents from five villages in the Ashanti Region, Ghana, were screened for Plasmodium species by rapid diagnostic test (RDT) and polymerase chain reaction (PCR) during the rainy season. Samples tested positive were subtyped using species-specific real-time PCR.

Molecular prevalence of asymptomatic Plasmodium infection was 284/391 (73%); only 126 (32%) infections were detected by RDT. While 266 (68%) participants were infected with Plasmodium falciparum, 33 (8%) were infected with Plasmodium malariae and 34 (9%) with P. ovale. The sub-species P. ovale curtisi and P. ovale wallikeri were identified to similar proportions. Non-falciparum infections usually presented as mixed infections with P. falciparum.

Most adult residents in the Ghanaian forest zone are asymptomatic Plasmodium carriers. The high Plasmodium prevalence not detected by RDT in adults highlights that malaria eradication efforts must target all members of the population. Beneath Plasmodium falciparum, screening and treatment must also include infections with P. malariae, P. o. curtisi and P. o. wallikeri.

Scientists shed new light on mechanisms of malaria parasite motility

eLife reports a new insight on the molecular mechanisms that allow malaria parasites to move and spread disease within their hosts has just been published. The first X-ray structures of the molecular complex that allows malaria parasites to spread disease highlight a novel target for antimalarial treatments.

The movement and infectivity of the parasite Plasmodium falciparum, and ultimately its ability to spread malaria among humans, rely on a large molecular complex called the glideosome. The new findings provide a blueprint for the design of future antimalarial treatments that target both the glideosome motor and the elements that regulate it.

New Lancet Series: Malaria in early life

Malaria infections are harmful to both the pregnant mother and the developing fetus. Malaria is associated with a 3–4 times increased risk of miscarriage and a substantially increased risk of stillbirth, and it disproportionately affects children younger than 5 years. Falciparum malaria is responsible for more than 200 000 child deaths per year in Africa and vivax malaria causes excess mortality in children in Asia and Oceania. In a duet of papers, we review 1) the deleterious effects of malaria in pregnancy on the developing fetus and 2) the current strategies for prevention and treatment of malaria in children.

Paper 1 is “Deleterious effects of malaria in pregnancy on the developing fetus: a review on prevention and treatment with antimalarial drugs” by Makoto Saito, Valérie Briand, Aung Myat Min, and Rose McGready. The authors are concerned that one in ten maternal deaths in malaria endemic countries may result from Plasmodium falciparum infection, that malaria is associated with a 3–4 times increased risk of miscarriage and a substantially increased risk of stillbirth. While current treatment and prevention strategies reduce, but do not eliminate, malaria’s damaging effects on pregnancy outcomes. They conclude that there is a need for alternative strategies to prevent malaria in pregnancy.

Paper 2 is “Treatment and prevention of malaria in children” by Elizabeth A Ashley and Jeanne Rini Poespoprodjo. They examine the following interventions: Triple antimalarial combination therapies, the RTS,S/AS01 vaccine, seasonal malaria chemoprevention and preventing relapse in Plasmodium vivax infection with primaquine.

Malaria News Today 2020-10-06: malaria in pregnancy, parasites surviving fever and private sector support

Today’s news featured a media briefing by the RBM Partnership and AMMREN on the challenges of protecting pregnant women from malaria. Additional news expands on these challenges. Research looks at how malaria parasites withstand the heat of a patient’s fever. Finally examples are presented of collaboration between international organizations and the private sector for malaria and disease control. Follow the links to gain more information.

Speed Up IPTp Scale-Up: a media briefing on maternal health

A panel discussion and media briefing on new approaches and lessons learned formed part of an online global call to end malaria in pregnancy with intermittent preventive treatment. The briefing on Tuesday, 6 October 2020, was sponsored by the Roll Back Malaria Partnership and AMMREN. The RBM website features background on the call to action.

The panel discussion included Dr. Aminata Cisse ep. Traore, Sous Directrice de la Santé de la Reproduction/Direction Générale de la Santé et de l’Hygiène Publique, Ministére de la Santé et de l’Hygiène Publique, Mali; Dr. Anshu Banerjee, Director Department of Maternal, Newborn, Child, Adolescent Health & Ageing, World Health Organization (WHO), and Dr. Pedro Alonso, Director Global Malaria Programme, WHO. The discussion was moderated by Mildred Komey, Malaria in Pregnancy Focal Person, National Malaria Control Program, Ghans Health Service.

The discussion covered the importance of launching this call now, what we’ve learned over the last few years, and examples of innovative strategies from Mali. There was a Q&A session with journalists after the presentations.

The presentation by Dr Alonso showed the progress in achieving IPTp coverage goals. He also pointed out the social and economic factors that affect access and equity to intermittent preventive treatment of malaria in pregnancy and protection of maternal health (see slides).

Experts say Africa must scale-up malaria protection for pregnant women

In support of the RBM/AMMREN briefing described above, Sola Ogundipe reports that amidst the COVID-19 pandemic in sub-Saharan Africa, malaria – one of the world’s oldest diseases – is impacting disproportionately on pregnant women and children aged under five.

For a pregnant woman, her fetus, and the newborn child malaria infection carries substantial risks. Calling for a speedy scale-up to boost protection against malaria for pregnant women in Africa, the Roll Back Malaria, RBM Partnership to End Malaria Working Group is issuing an urgent appeal to leaders and health policymakers to increase access to Intermittent Preventive Treatment during pregnancy, IPTp, among eligible pregnant women in sub-Saharan Africa.

Along with stakeholders, the RBM Partnership is pushing for scale-up coverage of three doses of IPTp to reach all eligible women in sub-Saharan Africa by 2025. In 2019, according to the RBM Partnership, an estimated 11 million pregnant women in sub-Saharan Africa, or 29 percent of all pregnancies were infected with malaria.

How malaria parasites withstand a fever’s heat

The parasites that cause 200 million cases of malaria each year can withstand feverish temperatures that make their human hosts miserable. Now, a team is beginning to understand how they do it. The researchers have identified a lipid-protein combo that springs into action to gird the parasite’s innards against heat shock.

Understanding how malaria protects its cells against heat and other onslaughts could lead to new ways to fight tough-to-kill strains, researchers say. Findings could lead to ways to maximize our existing antimalarial arsenal.

Global Fund and Chevron – United Against HIV, TB and Malaria

The Global Fund and Chevron Corporation have celebrated a 12-year partnership that served as an example of the private sector’s contribution to the fight against infectious diseases and to building resilient health systems. Chevron, a Global Fund partner since January 2008, has supported Global Fund programs against HIX4 tuberculosis and malaria for a total investment of US$60 million in Angola, Indonesia, Nigeria, the Philippines, South Africa, Thailand and Vietnam.

Chevron’s partnership has contributed to helping more than a million people living with HIV access lifesaving antiretroviral therapy; supported efforts to distribute over one million long-lasting insecticide-treated mosquito nets to families to prevent malaria; helped detect thousands of TB cases; promoted education programs for the young, and helped build stronger health systems.

In Nigeria, Chevron’s $5 million investment from October 2017 to December 201 9 supported the national HIV and TB programs, reaching key and vulnerable populations, as well as interventions aimed at strengthening the health system. Sustainable and resilient systems for health are indispensable in the fight against the epidemics of HIV TB and malaria, as well as the first line of defense against new diseases like COVID-19. “With rising cases of COVID-1 9, the stakes are very high. Deaths from HIV, TB and malaria are likely to increase. Investments by partners like Chevron are fundamental.