Low birth weight and fetal anaemia as risk factors for infant morbidity in rural Malawi

Low birth weight (LBW) and fetal anaemia (FA) are common in malaria endemic areas. To investigate the incidence of infectious morbidity in infants in rural Malawi in relation to birth weight and fetal anaemia, a cohort of babies was followed for a year on the basis of LBW (<2500) and FA (cord haemoglobin <12.5g/dl). A matched group of normal birth weight (NBW), non-anaemic (NFA) new-borns were enrolled as controls. Morbidity episodes were recorded at 4-weekly intervals and at each extra visit made to a health centre with any illness. Infants in the NBW NFA group experienced an average of 1.15 (95% C.I. 0.99, 1.31), 1.04 (0.89, 1.19), 0.92 (0.73, 1.11) episodes per year of malaria, respiratory infection and diarrhoea respectively. Corresponding values for the LBW FA group were 0.83 (0.5, 1.16), 0.82 (0.5, 1.16) and 0.76 (0.33, 1.19). FA was not associated with a higher incidence of morbidity, but was significantly associated with a shorter time to first illness episode (p=0.014). LBW was not a significant risk factor for higher morbidity incidence. LBW and FA were not significant risk factors for incidence of illness episodes in infants.     

Outcomes of asymptomatic malaria parasitaemia in neonates in a tertiary hospital,southeast Nigeria

Background:

Malaria infestation during pregnancy is mostly asymptomatic and untreated especially in unbooked pregnancies. It presents with almost all the fetal complications of overt malaria in pregnancy. The aim of this study was to determine the effect of asymptomatic malaria parasitaemia on the neonates of unbooked parturients delivered at term at the Federal Teaching Hospital, Abakaliki.

Materials and Methods:

This study was conducted in the labour ward complex of the Federal Teaching Hospital, Abakaliki from March to May 2012. Unbooked pregnant women who fulfilled the inclusion criteria and gave consent were consecutively recruited. Cord blood and placenta tissue were collected for haemoglobin concentration determination and histology, respectively. Birth weights were determined with an electronic weighing machine. Statistical Analysis was done with 2008 Epi Info™ software and level of significant was set at P-value <0.05.

Results:

A total of 250 unbooked parturients were recruited, of which 194 (77.6%) had asymptomatic malaria parasitaemia while 227 (90.8%) had placental parasitisation. The prevalence of low birth weight in the study was 16.4%. There was significant relationship between asymptomatic malaria parasitemia and birth weight (X² = 43.70, P-value < 0.001). There were no low-birth-weight deliveries among paturients without placental parasitemia. No neonate, however, had anaemia in the study.

Conclusion:

Asymptomatic malaria parasitemia and placental parasitisation by malaria parasites contribute to the outcome of the foetal birth weight. Asymptomatic malaria parasitaemia and placental parasitaemia did not result in a corresponding foetal anaemia on babies delivered.     

Neurocognitive sequelae of cerebral malaria in adults: A pilot study in Benguela Central Hospital,Angola

Objective

To characterize the neurocognitive sequelae of cerebral malaria (CM) in an adult sample of the city of Benguela, Angola.

Methods

A neuropsychological assessment was carried out in 22 subjects with prior history of CM ranging from 6 to 12 months after the infection. The obtained results were compared to a control group with no previous history of cerebral malaria. The study was conducted in Benguela Central Hospital, Angola in 2011.

Results

CM group obtained lower results on the two last trials of a verbal learning task and on an abstract reasoning test.

Conclusions

CM is associated to a slower verbal learning rate and to difficulties in the ability to discriminate and perceive relations between new elements.     

In-vivo parasitological response to sulfadoxine-pyrimethamine in pregnant women in southern Malawi

Background

Malaria in pregnancy is a significant cause of maternal and infant morbidity and mortality. Malawi adopted intermittent preventive treatment with sulfadoxinepyrimethamine (SP) for the control of malaria in pregnancy in 1993. However there is little information on the in-vivo SP efficacy in pregnant women. This study was conducted to determine: prevalence of malaria and anaemia at the first antenatal visit and rate of parasitological failure to SP in pregnancy.

Methods

A cross-sectional followed by a prospective cohort study was conducted in women attending antenatal care clinic at Montfort Hospital in Lower Shire Valley from June 2004 to February 2005. Women were screened for malaria and anaemia at the first antenatal visit. After taking SP under direct observation, women with malaria parasitaemia were followed up to day 14 to determine parasitological response.

Results

Of 961 women screened, 9% had malaria, 77% had anaemia (HB<11.0g/dl), 24% had moderate anaemia (HB 7.0-8.9g/dl) and 6% had severe anaemia (HB<7.0g/dl). Malaria was significantly more frequent in primigravidae, the second trimester and in the post- rainy season (all p <0.05). Moderate anaemia (Hb < 9.0g/dl) was significantly more common in adolescents and primigravidae (both p <0.05). In the14-day follow up study, loss to follow up was 13%. Of the 74 women who completed the follow up, 89% cleared malaria parasites successfully and 11% had parasitological failure. Parasitological failures were all of the R1 type except for one with R2 failure.

Conclusion

Anaemia prevalence was high at first antenatal visit in this population. Rate of parasitological failure to SP in pregnancy increased from 5% in 1996 to 11% in 2004.     

Prevalence of malaria infection in Sarbaz,Sistan and Bluchistan province

Objective

To survey malaria prevalence in Sarbaz from April 2009 to October 2010.

Methods

Epidemiological data of 1 464 confirmed malarial patients were analyzed according to demographic status, sex, age, nationality, isolated species and residence place.

Results

The majority of patients were male 950 (64.8%) but 514 (35.2%) were female. 82.5% of patients were Iranian, 14% Pakistani immigrants, and 3.5% Afghan immigrants. Data collected showed that 90% of isolated species were Plasmodium vivax, 7.8% Plasmodium falciparum, and 2.2% Plasmodium malariae and mixed species.

Conclusions

Therefore, it is crystal clear that refugees should be prohibited by government and controlled by experts in health centers in order to campaign effectively with this life threating disease.     

Electronic Health Records in Four Community Physician Practices: Impact on Quality and Cost of Care

Objective

To assess the impact of the electronic health record (EHR) on cost (i.e., payments to providers) and process measures of quality of care.

Study Design

Retrospective before-after-study-control. From the database of a large managed care organization (MCO), we obtained the claims of patients from four community physician practices that implemented the EHR and from about 50 comparison practices without the EHR in the same counties. The diverse patient and practice populations were chosen to be a sample more representative of typical private practices than has previously been studied.

Measurements

For four chronic conditions, we used commercially-available software to analyze cost per episode over a year and the rate of adherence to clinical guidelines as a measure of quality.

Results

The implementation of the EHR had a modest positive impact on the quality measure of guideline adherence for hypertension and hyperlipidemia, but no significant impact for diabetes and coronary artery disease. No measurable impact on the short-term cost per episode was found. Discussions with the study practices revealed that the timing and comprehensiveness of EHR implementation varied across practices, creating an intervention variable that was heterogeneous.

Conclusions

Guideline adherence increased across practices without EHRs and slightly faster in practices with EHRs. Measuring the impact of EHRs on cost per episode was challenging, because of the difficulty of completely capturing the long-term episodic costs of a chronic condition. Few practices associated with the study MCO had implemented EHRs in any form, much less utilizing standardized protocols.     

Use of buffy coat thick films in detecting malaria parasites in patients with negative conventional thick films

Objective

To determine the frequency of malaria parasite detection from the buffy coat blood films by using capillary tube in falciparum malaria patients with negative conventional thick films.

Methods

Thirty six uncomplicated falciparum malaria patients confirmed by conventional thick and thin films were included in the study. The patients were treated with artemisinin combination therapy at Hospital for Tropical Diseases, Bangkok, Thailand for 28 day. Fingerpricks for conventional blood films were conducted every 6 hours until negative parasitemia, then daily fingerpricks for parasite checks were conducted until the patients were discharged from hospital. Blood samples were also concurrently collected in 3 heparinized capillary tubes at the same time of fingerpricks for conventional blood films when the prior parasitemia was negative on thin films and parasitemia was lower than 50 parasites/200 white blood cells by thick film. The first negative conventional thick films were compared with buffy coat thick films for parasite identification.

Results

Out of 36 patients with thick films showing negative for asexual forms of parasites, buffy coat films could detect remaining 10 patients (27.8%) with asexual forms of Plasmodium falciparum.

Conclusions

The study shows that buffy coat thick films are useful and can detect malarial parasites in 27.8% of patients whose conventional thick films show negative parasitemia.     

Efficacy of Amodiaquine/Artesunate Combination Therapy for Uncomplicated Malaria in Children Under Five Years in Ghana

Background

In 2005, following several years of declining efficacy of chloroquine, the Ministry of Health recommended the use of Amodiaquine/Artesunate combination therapy for the treatment of uncomplicated malaria. A system of continuous monitoring of therapeutic responses has been established in 10 district hospitals across the country. The data gathered will enable National Malaria Control Programme (NMCP) to respond to changes in the efficacy of the new treatment in a timely manner.

Objectives

To determine the 28 day therapeutic efficacy of Amodiaquine/Artesunate (AQ/AS) combination treatment in children with uncomplicated malaria in Ghana.

Methods

Children aged 6 – 59 months attending clinic with signs/symptoms of uncomplicated malaria at 9 district hospitals (3 in each of the 3 eco-epidemiological zones of the country) were eligible for enrolment. Enrolled children were followed up after treatment for a total of 28 days to record the clinical and parasitological resolution of their malaria episode as well as any adverse drug reactions.

Results

Treatment resulted in rapid and complete cure in almost all the children; 99.3% 14 days after treatment and 93.0%, 28 days after treatment. The majority of treatment failures on D28 were seen in the 3 sites located in the forest zones (Sunyani, Bekwai and Begoro). There was no case of Early Treatment Failure at both D14 and D28 assessments. Adverse events (AE''s) were minimal, less than 4%, with the most common complaint being vomiting.

Conclusion

AQ/AS combination for uncomplicated malaria is efficacious and safe in children less than 5 years.     

Resolution pattern of jaundice among children presenting with severe malaria in rural South-West Nigeria

Objective

To compare the pattern of jaundice resolution among children with severe malaria treated with quinine and artemether.

Methods

Thirty two children who fulfilled the inclusion criteria were recruited for the study from two hospitals with intensive care facilities. They were divided into two groups; ‘Q’ and ‘A’, receiving quinine and artemether, respectively. Jaundice was assessed by clinical examination.

Results

Sixteen out of 32 children recruited (representing 50%) presented with jaundice on the day of recruitment. The mean age was (7.00°C2.56) years. On day 3, four patients in ‘A’ and six patients in ‘Q’ had jaundice. By day 7, no child had jaundice.

Conclusion

The study has shown that both drugs resolve jaundice although artemether relatively resolves it faster by the third day.     

A comparative laboratory diagnosis of malaria: microscopy versus rapid diagnostic test kits

Objective

To compare the two methods of rapid diagnostic tests (RDTs) and microscopy in the diagnosis of malaria.

Methods

RDTs and microscopy were carried out to diagnose malaria. Percentage malaria parasitaemia was calculated on thin films and all non-acute cases of plasmodiasis with less than 0.001% malaria parasitaemia were regarded as negative. Results were simply presented as percentage positive of the total number of patients under study. The results of RDTs were compared to those of microscopy while those of RDTs based on antigen were compared to those of RDTs based on antibody. Patients'' follow-up was made for all cases.

Results

All the 200 patients under present study tested positive to RDTs based on malaria antibodies (serum) method (100%). 128 out of 200 tested positive to RDTs based on malaria antigen (whole blood) method (64%), while 118 out of 200 patients under present study tested positive to visual microscopy of Lieshman and diluted Giemsa (59%). All patients that tested positive to microscopy also tested positive to RDTs based on antigen. All patients on the second day of follow-up were non-febrile and had antimalaria drugs.

Conclusions

We conclude based on the present study that the RDTs based on malaria antigen (whole blood) method is as specific as the traditional microscopy and even appears more sensitive than microscopy. The RDTs based on antibody (serum) method is unspecific thus it should not be encouraged. It is most likely that Africa being an endemic region, formation of certain levels of malaria antibody may not be uncommon. The present study also supports the opinion that a good number of febrile cases is not due to malaria. We support WHO''s report on cost effectiveness of RDTs but, recommend that only the antigen based method should possibly, be adopted in Africa and other malaria endemic regions of the world.     

A pilot study to evaluate the diagnostic accuracy of local terminology for malaria screening among children in rural Malawi

Background

Malaria is a serious health problem in Malawi. It is responsible for 43% of all out patient visits and 19% of all deaths occurring to children under five years of age. Rapid diagnosis and appropriate treatment can avert most malaria deaths. However this is not always possible in resource limited settings where functioning laboratories are almost nonexistent.

Methods

This paper assesses the accuracy of local terminology in detecting parasitemia in children using blood smears as the reference standard.

Results

The study observes that there are local terms that can be used as an inexpensive, readily available and easily implementable malaria screening test in Malawian children in rural areas. These terms include “malungo” (official name for malaria), “kutentha thupi” (hot body), “kutsegula m''mimba” (official term for diarrhoea) and “kukhosomola” (coughing). The local terms “malungo” and “kutentha thupi” yielded better results.

Conclusion

Although the local terminology produced results that are less than optimal, the study concludes that the knowledge of sensitivity and specificity of local terminology can be used by local healthcare practitioners to identify children who could benefit from malaria confirmation testing and presumptive treatment. The study, however, cautions that these terms should be used as an entry point to malaria case management as they do not distinguish the severity of the malaria infection and all of them produced a sensitivity of less than 50%.     

Epidemiological Investigation of Forest Malaria among GREF and Army Personnel

Background

General Reserve Engineering Forces (GREF) engaged in road construction and military personnel camping in forest areas are at high risk of contacting malaria.

Method

All cases of malaria were confirmed by peripheral blood smear examination. Neighbouring civilian houses were visited, members interviewed and blood slides taken. Environmental survey included mosquito and larval collection. Epidemiological data on malaria in the state and the district was obtained from civil health authorities.

Results

During April-June 2001 there were 27 cases of malaria amongst GREF and army personnel out of 91 deployed giving an attack rate of 29.67%. The attack rate was significantly more in GREF personnel (45%) compared to army personnel (17.65%). All the cases were falciparum malaria. Out of 20 randomly collected blood slides from the civil laborers, 2 (10%) were positive for falciparum malaria.

Conclusion

For small patrols operating in hyperendemic malarious areas strict personnel protective measures besides chemoprophylaxis needs to be implemented.Key Words: Forest malaria, Falciparum, Army     

Malaria in Pregnancy

Background

Malaria in pregnancy contributes to low birth weight and increased infant mortality.

Methods

The study included 416 pregnant women reporting with fever and the impact of malaria on pregnancy was assessed.

Result

The study revealed that the protozoal infection affects second trimester more commonly. It increases the chances of abortions, intrapartum foetal distress and meconium stained amniotic fluid.

Conclusion

Malaria is an important cause of feto-maternal morbidity during pregnancy.Key Words: Malaria in pregnancy, Plasmodium     

Impact of maternal body mass index on neonatal outcome

Introduction

Maternal body mass index has an impact on maternal and fetal pregnancy outcome. An increased maternal BMI is known to be associated with admission of the newborn to a neonatal care unit. The reasons and impact of this admission on fetal outcome, however, are unknown so far.

Objective

The aim of our study was to investigate the impact of maternal BMI on maternal and fetal pregnancy outcome with special focus on the children admitted to a neonatal care unit.

Methods

A cohort of 2049 non-diabetic mothers giving birth in the Charite university hospital was prospectively studied. The impact of maternal BMI on maternal and fetal outcome parameters was tested using multivariate regression analysis. Outcome of children admitted to a neonatal ward (n = 505) was analysed.

Results

Increased maternal BMI was associated with an increased risk for hypertensive complications, peripheral edema, caesarean section, fetal macrosomia and admission of the newborn to a neonatal care unit, whereas decreased BMI was associated with preterm birth and lower birthweight. In the neonatal ward children from obese mothers are characterized by hypoglycaemia. They need less oxygen, and exhibit a shorter stay on the neonatal ward compared to children from normal weight mothers, whereas children from underweight mothers are characterized by lower umbilical blood pH and increased incidence of death corresponding to increased prevalence of preterm birth.

Conclusion

Pregnancy outcome is worst in babies from mothers with low body mass index as compared to healthy weight mothers with respect to increased incidence of preterm birth, lower birth weight and increased neonate mortality on the neonatal ward. We demonstrate that the increased risk for neonatal admission in children from obese mothers does not necessarily indicate severe fetal impairment.     

Immunochromatographic Methods in Malaria Diagnosis

Background

Malaria remains a major cause of morbidity and mortality in India. This study was carried out to evaluate the use of parasite lactate dehydrogenase (pLDH) test in diagnosis of malaria.

Methods

Blood slides of 400 patients who presented with fever including 104 patients with clinical features suggestive of malaria were studied. The results were compared with microscopy and another immunochromatography test (ICT) based on detection of histidine rich protein-2 antigen [Pfhrp-2] secreted by Plasmodium falciparum.

Result

In this study the sensitivity and specificity for detection of Plasmodium vivax was 100% while for Plasmodium falciparum the values were 96% and 100% respectively.

Conclusion

ICT is useful for diagnosis of malaria caused by Plasmodium falciparum in field but microscopy of a well-prepared blood smear must not be omitted in a laboratory setting.Key Words: Malaria, Immunochromatography     

Sentinel surveillance of lymphatic filariasis, schistosomiasis soil transmitted helminths and malaria in rural southern Malawi

Background

Baseline prevalence and knowledge, attitude and perception (KAP) survey is a prerequisite for mass drug administration for the control of Lymphatic filariasis (LF) and other neglected tropical diseases.

Methods

In preparation for the first mass drug administration for LF elimination, a baseline survey was conducted in six sentinel sites in the southern Malawi, amongst participants aged five years or more. A standard questionnaire was used to obtain data on socio-demographic factors, ownership and use of bed nets, previous ingestion of ivermectin and KAP toward hydrocele and lymphoedema. Finger prick blood samples were collected from 22:00 to 01:00 hours for LF microscopy, malaria and haemoglobin examination. Stool and urine samples were collected for internal helminths and schistosomiasis respectively.

Results

A total of 1, 903 participants were enrolled. Knowledge on the cause of hydrocele and lymphoedema was low in all the sentinel sites (16%–42%, 10%–24% (respectively). Sexual intercourse with a menstruating woman, bad weather and HIV/AIDS were perceived causes of hydrocele. Microfilaraemia prevalence was 1.5% and varied little between sentinel sites (1.0%–2.1%). Childhood urinary schistosomiasis was common in Phalombe (94.9%) and Blantyre (26.9%).

Conclusion

Integrated approach and understanding of the community KAP is vital or successful implementation of LF elimination programme.     

Malaria on the Move : Ecological Considerations for the Armed Forces

Background

Armed forces personnel deployed in the North Eastern states of India are vulnerable to falciparum malaria. This vulnerability increases during mobilization of troops.

Methods

Epidemiological case sheet was used for recording individual movement, clinical features and laboratory investigations of each case of malaria. Immunochromotography test (ICT) or Paracheck Pf was used as a rapid test for falciparum malaria at the regimental aid post (RAP). Subsequently, a case control approach was used to ascertain whether the cases of malaria differed significantly from healthy controls in observing antimalaria measures such as the use of mosquito nets, repellants and chemoprophylaxis.

Result

Nineteen out of 623 soldiers suffered from falciparum malaria during a short period of ten days during operational mobilization. Use of mosquito nets and repellants was significantly less among the cases as compared to healthy controls. There was no significant difference among the two groups regarding compliance with chemoprophylaxis.

Conclusion

A paradigm of “malaria on the move” or “operational malaria” has been proposed.Key Words: Malaria, Armed Forces, Mobilization     

Hematological indices in febrile neonates with malaria parasitaemia in Calabar

Background:

Normal hematological indices has been determined in Nigerian newborns and found to be lower compared to their Caucasian counterparts. This was attributed to genetic factors. Malaria is endemic in Nigeria and is one of the major causes of ill health and death. Anemia is an important manifestation of malaria. Resistance by malaria parasites to antimalarial drug exacerbates the situation by continuous hemolysis.

Aim:

To determine the hematological indices in febrile newborn with malaria parasitemia.

Materials and Methods:

One-hundred fifty neonates (0-28 days) with fever admitted into the Newborn Unit of University of Calabar Teaching Hospital, over a 6 months period, were recruited consecutively. Blood film for malaria parasites and samples for full blood count were obtained and sent to the laboratory before commencement of the treatment. Data analysis was with SPSS version 14.

Results:

One-hundred fifty babies were recruited into the study. Most (85.3%) of the babies were aged ≤7 days. Six babies (4%) had malaria parasitemia. Plasmodium falciparum was the only species identified. All the babies that had parasitemia were anemic (mean hemoglobin [Hb] concentration of 12.6 g/dl) even when parasite count was low (average of 30.6/µl) though this could not be attributed solely to malaria. None of these neonates was transfused. All the other hematological indices were within the normal range of healthy newborn population irrespective of parasitization.

Conclusion:

Neonatal malaria does occur in our environment. While it does not affect the white blood indices, it lowers neonatal Hb. It is recommended that Hb concentration be estimated in newborns with malaria to reduce infant morbidity and mortality in our environment.     

Clinical presentation and incidence of complications in patients with coeliac disease diagnosed by relative screening

Background

There is an increased prevalence of coeliac disease (CD) among relatives of those with the disease.

Aims

To compare the clinical features in patients with CD detected via family screening with those in patients diagnosed routinely.

Methods

Information on screening was provided to relatives of patients. Those who wished to be screened were tested for endomysial and/or tissue transglutaminase antibodies. Duodenal biopsy was performed in those with positive antibodies. The clinical details of the relative screening group were compared with those of 105 patients diagnosed routinely.

Results

183 relatives underwent screening, of whom 32 had positive serology, 24 had histology diagnostic of CD, six had normal biopsies and two declined duodenal biopsy. Patients in the relative screening group were younger with a median age of 33 years (range 17–72 years) compared to the routine group which had a median age of 54 years (range 25–88 years). In the relative screening group, there was a male preponderance (M:F ratio 16:8), anaemia at presentation was significantly less common (13% v 58%; p<0.001) and osteoporosis was less frequent (9% v 22%; p<0.244) compared with the routine group. 65% of the relative screening group had gastrointestinal symptoms or anaemia at diagnosis.

Conclusions

Patients detected by family screening are younger with a male preponderance, but fewer had anaemia and osteoporosis.