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The Malaria in Pregnancy (MiP) Library is a regularly updated, comprehensive bibliographic database of published and unpublished literature relating to malaria in pregnancy, including a trial registry of planned and ongoing trials. The MiP library is a product of the Malaria in Pregnancy Consortium and is available free of charge.

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march_2020

Article highlights from the update in April-May 2020:

 

In May 2020, 134 new entries were added to the MiP library. New entries include peer reviewed journal articles, PhD and MSc theses, reports, and conference abstracts. Here we highlight new articles that may be of particular interest.

At a time when most parts of the world must face the reality that COVID-19 is here to stay, the Roll Back Malaria partnership has published "Practical guidance for delivery of malaria in pregnancy interventions through antenatal care during the COVID-19 Pandemic" to help countries ensure protective practices so that their antenatal care services are safe and that malaria prevention is not neglected (Practical guidance).

A cluster-randomized trial investigated the effect of group versus individual antenatal care of pregnant women in Kenya and Nigeria (Grenier et al. 2019; Noguchi et al. 2020). In the intervention arm, groups of 8-15 women of similar gestational age followed five sessions of up to 2 hours which included participatory, facilitated learning, activities and peer support with clinical assessments; outcome data was obtained through facility records and a home-based postpartum survey. Compared to the control arm, women in the intervention arm were more likely to attend at least four antenatal visits (91% vs 42.3% in Nigeria and 88.2% vs. 50.1% in Kenya), and were having a higher mean number of intermittent preventive treatment (IPTp) doses (3.5 vs. 2.1 in Nigeria, and 3.8 vs. 2.7 in Kenya); facility based deliveries (76.7% vs. 54.1%) and postpartum insecticide-treated net (ITN) use by infants (82.7% vs. 75.8%) were higher in Nigeria in the intervention arm compared to control. Sirima et al. 2020 report on the first human trial of PRIMVAC (malaria vaccine adjuvanted with Alhydrogel or GLA-SE) among non-pregnant women in France and Burkina Faso and noted that PRIMVAC had an acceptable safety profile, was immunogenic, and induced functional antibodies reacting with the homologous VAR2CSA variant expressed by NF54-CSA infected erythrocytes. This will form the basis for further vaccine development.

A qualitative study by Hildon et al. (2020) examined decision-making processes with regards to malaria prevention during pregnancy in Mozambique (Hildon et al. 2020). Using bednets was generally within the women's domain who were generally tasked with hanging, washing and making nets usable. Net purchase and appropriation for malaria prevention (rather than for instance for fishing) was men's prerogative. Attending antenatal care to access intermittent preventive treatment during pregnancy was often a decision under the purview of older, influential women and ultimately needed sanctioning by men. With respect to seeking care for malaria symptoms, women typically sought help from traditional healers first. This treatment decision was within their control, in contrast to the frequently transport-dependent decision to attend a health facility. In Ethiopia, (Gultie et al. 2020) report a worrying decreasing trend in ITN use by pregnant women, from 83.6% in 2010 to 36.5% in 2016. Scates et al. 2020 explored the costs of different ITN distribution systems in African countries; the results suggest that continuous distribution strategies through antenatal services and immunization programs can continue to deliver nets at a comparable cost to mass distributions, especially from the perspective of the donor.


In a project to pilot community distribution of IPTp, a household survey was conducted among recently pregnant women in Malawi (Malpass et al. 2020); among 370 women, 77.9% found community health workers (CHW) helpful because of their care and easy availability, but antenatal clinic (ANC) and malaria prevention was not the focus of the interactions. Adequate knowledge of malaria among participants was associated with increased odds of receiving IPTp3+ in the ANC. In a feasibility study to evaluate intermittent screening and treatment in pregnancy (ISTp) in India, a qualitative study assessed perceptions of women and health workers (Webster et al. 2020); only 8% of women in the ISTp arm who had completed their pregnancy received a rapid diagnostic test (RDT) on three visits to ANC. Health workers were however positive about ISTp mainly because of their perception that many pregnant women with malaria were asymptomatic. Health workers perceived pregnant women to have reservations about ISTp because of their dislike of frequent blood withdrawal, but pregnant women themselves were more positive.

A systematic review (Patson et al. 2020) evaluated statistical methods for safety data in 18 malaria chemoprevention trials in pregnancy and noted that these analyses were often inadequate, with insufficient accounting for potential dependence between outcomes, follow-up time and informative missing data; this can compromise anti-malarial drug safety evidence development. Cutts et al. (2020) reviewed the association between pregnancy-specific malarial immunity and the risk of malaria in pregnancy and adverse birth outcome; because of the wide variation in reported antibody responses, 16 studies contributed estimates in a format enabling inclusion in meta-analysis and 17 were included in narrative form only. They conclude that whilst antibody responses to several antigens were positively associated with the presence of placental and peripheral infections, this review did not identify evidence that any specific antibody response is associated with protection from pregnancy-associated malaria across multiple populations. Lopez-Perez 2020 has a note of caution on the use of recombinant proteins for the evaluation of antibody responses in malaria in pregnancy studies.

There is concern about increasing drug resistance to SP and reduced efficacy of IPTp in Africa. Taylor et al. 2020 examined if there was a different effect of wild type (n=107) or dhps A581G-bearing placental parasites (n=18) on birth weight among participants in a trial comparing intermittent screening and treatment versus IPTp in Malawi. The A581G-bearing parasites were found in both the IST arm (n=9) and the IPTp arm (9) and were associated with a reduction of birthweight of 412 grams compared to the wild-type parasites. However, in the IPTp arm, recent SP use was not associated with increased morbidity among women carrying the A581G-bearing parasites at delivery. The prevalence of the dhps A581G mutation was estimated to be between 12.7 to 47.2% in four sites in North and South Kivu in the Democratic Republic of Congo in 2017 (1229 samples, van Lenthe et al. 2019), and 12.8% (141 samples) in Southern Ghana in 2017 (Tornyigah et al. 2020).

Studies from Burkina Faso show the usefulness of routinely collected data, such as for the production of risk maps for malaria in pregnancy and to evaluate the effect of IPTp programs on the malaria burden overall and severe malaria among pregnant women (Rouamba et al. 2020). The severe malaria fatality rate among pregnant women in Burkina Faso decreased significantly with proper coverage of 3+ doses of IPTp-SP (Rouamba et al. 2020 ). Augusto et al. 2020 reported that artemisinin-based chemotherapy (ACT) exposure during the first trimester was not associated with an increased occurrence of low birth weight (10/92 or 10.9% versus 171/1797 or 9.5% among non-exposed women), providing further reassurance for use in the first trimester. However, the data suggested a higher prevalence of low birth weight for children born to quinine-exposed pregnancies (7/26).

A study in Indonesia compared the performance of ultra-sensitive rapid diagnostic tests and normal RDTs with PCR and LAMP as reference standard and did not find an advantage of the ultrasensitive tests for the detection of asymptomatic falciparum malaria (Unwin et al. 2020 ). Lastly, using a case-report, (Brummaier et al. 2020) exposed how the combined problems of adverse effects of vivax malaria in pregnancy, the ineligibility of radical cure for pregnant and postpartum women, and difficulties in diagnosing intermediate levels of G6PD activity can lead to multiplied morbidity in women.