Socio-economic behavioural indicators of falciparum malaria parasitaemia and moderate to severe anaemia among pregnant women attending antenatal clinics in Lagos, Southwest Nigeria.

BACKGROUND: Incidence of malaria and anaemia are of public health importance especially in pregnant women in endemic regions, due to the negative health consequences to the mother and fetus. This study aimed to assess the pattern of falciparum malaria infection and anaemia, based on malaria prevention methods practiced by participants. METHODS: A semi-structured tool was used to capture information on demographic, socio-economic and malaria prevention practices from 113 pregnant women attending antenatal clinics in 2 peri-urban health facilities in Lagos, southwest Nigeria. Malaria microscopy was conducted and haematocrit was measured. Logistic regression analysis was performed on the data collated from the survey. RESULTS: The prevalence of anaemia among pregnant women was 87.2%. The mean (± sd) packed cell volume (PCV) (%) of the 22 (19.5%) infected subjects (26.8 ± 6.6), was significantly lower (t = -2.60, P value = 0.007) than that of the 91 (80.5%) uninfected subjects (30.8 ± 6.0). The prevalence of infection was highest in the 3rd trimester (n = 40, 35.4%) at 27.5% (11/40) and among those in their first pregnancy (n = 32, 28.3%) at 25.0% (8/32). There was a significant difference (t = -2.23, P-value = 0.01) in the mean PCV % of pregnant women who consumed herbal teas in pregnancy (28.2 ± 5.2) compared to those who did not (30.8 ± 6.6). Regression analysis showed that first pregnancy, anti-malarial use and insecticide-treated nets use the night before study had increased odds of malaria infection in participants (OR = 1.35, P = 0.006, 95% CI 0.52-2.49; OR = 2.3, P = 0.005, 95% CI 0.14-0.41; OR = 1.92, P = 0.001, 95% CI 0.62-5.98) while intermittent preventive treatment (IPT) participation and formal education were strongly and significantly associated with lower risk of parasitaemia (OR = 0.95, P = 0.025, 95% CI 0.41-2.26; OR = 0.44, P = 0.005, 95% CI 0.34-10.50). CONCLUSION: Interventions that will reduce malaria and moderate to severe anaemia, especially in a first pregnancy, should include education on the correct use of long-lasting insecticide-treated bed nets (LLIN), IPT and the dangers of herbal teas in pregnancy.

Impact of Malnutrition on Serum Levels of Pro-inflammatory Cytokines among Plasmodium falciparum Malaria Subjects in Nigeria.

BACKGROUND: Understanding the impact of malnutrition on innate immune response in Plasmodium falciparum (Pf)-infected subjects is critical for malaria control. AIMS AND OBJECTIVES: This study aims to investigate the nutritional status and innate immune response of Pf-infected subjects in Lagos, Nigeria. MATERIALS AND METHODS: A total of 1183 patients with a history of fever or axillary temperature ≥37°C were screened microscopically for Pf at Ijede General Hospital, Lagos, Nigeria. Malnutrition was determined according to the U.S National Center for Health Statistics (NCHS) as stunting, wasting, or underweight when the Z-score is <-2 in the participants aged <20 years. Serum levels of tumor necrosis factor-alpha (TNF-α), interleukin-1ß (IL-1ß), and IL-12 were determined by capture ELISA while hematological parameters were measured using an automated hematology system. RESULTS: A total of 384 volunteers were positive for Pf, of which 114 were <20 years with a median age of 10 years. Overall malaria prevalence was 20.89%. The malnutrition rate was 89.5%; 24 (21.05%) were stunted, 30 (26.32%) were underweight, and 48 (42.11%) were wasted. Pro-inflammatory cytokine responses were not affected by the type of malaria. TNF-α was higher in participants <5 years (P = 0.001) and in malnourished patients (P < 0.05). CONCLUSION: Together, it could be deduced that nutritional status influences Plasmodium falciparum malaria outcomes and progression pattern.

Résumé Contexte:Comprendre l'impact de la malnutrition sur la réponse immunitaire innée chez les sujets infectés par Plasmodium falciparum (Pf) est essentiel pour la lutte contre le paludisme.Buts et objectifs:Cette étude vise à étudier l'état nutritionnel et la réponse immunitaire innée des sujets infectés par Pf à Lagos, au Nigeria.Matériels et méthodes:Un total de 1183 patients ayant des antécédents de fièvre ou une température axillaire ≥37°C ont fait l'objet d'un dépistage microscopique de Pf à l'hôpital général Ijede, Lagos, Nigeria. La malnutrition a été déterminée selon le National Center for Health Statistics (NCHS) des États-Unis comme un retard de croissance, une émaciation ou une insuffisance pondérale lorsque le score Z est <-2 chez les participants âgés de moins de 20 ans. Les taux sériques de facteur de nécrose tumorale alpha (TNF-α), d'interleukine-1ß (IL-1ß) et d'IL-12 ont été déterminés par capture ELISA, tandis que les paramètres hématologiques ont été mesurés à l'aide d'un système d'hématologie automatisé.Résultats:Au total, 384 volontaires étaient positifs pour le Pf, dont 114 étaient âgés de moins de 20 ans avec un âge médian de 10 ans. La prévalence globale du paludisme était de 20,89 %. Le taux de malnutrition était de 89,5 %; 24 (21,05 %) souffraient d'un retard de croissance, 30 (26,32 %) d'une insuffisance pondérale et 48 (42,11 %) d'émaciation. Les réponses des cytokines pro-inflammatoires n'ont pas été affectées par le type de paludisme. Le TNF-α était plus élevé chez les participants de moins de 5 ans ( P = 0,001) et chez les patients souffrant de malnutrition ( P < 0,05).Conclusion:On peut en déduire que l'état nutritionnel peut influencer les résultats et le schéma de progression du paludisme.

Impact of training of mothers, drug shop attendants and voluntary health workers on effective diagnosis and treatment of malaria in Lagos, Nigeria.

BACKGROUND: The National Malaria Eradication Program and international agencies are keen on scaling up the use of malaria rapid diagnostic tests (mRDTs) and artemisinin-based combination therapies (ACTs) for effective diagnosis and treatment of the disease. However, poor diagnostic skills and inappropriate treatment are limiting the efforts. In Nigeria, a large proportion of infected patients self-diagnose and treat while many others seek care from informal drug attendants and voluntary health workers. AIMS: This study describes the impact of training voluntary health workers, drug shop attendants, and mothers on effective case detection and treatment of malaria in Lagos, Nigeria. METHODS: We trained mothers accessing antenatal care, drug shop attendants, and voluntary health workers selected from the three districts of Lagos, on the use of histidine-rich protein-2-based mRDTs and ACTs. Pre- and post-training assessments, focus group discussions (FGDs), and in-depth interviews (IDIs) were carried out. RESULTS: The knowledge, attitude, and skill of the participants to achieve the goal of "test, treat, and track" using mRDT and ACTs were low (11%-55%). There was a low awareness of other non-malaria fevers among mothers. Self-medication was widely practiced (31.3%). FGDs and IDIs revealed that health-care providers administered antimalarials without diagnosis. Training significantly improved participants' knowledge and expertise on the use of mRDTs and ACTs (P = 0.02). The participants' field performance on mRDT use was significantly correlated with their category (bivariate r = 0.51, P = 0.001). There was no statistically significant association between the participants' level of education or previous field experience and their field performance on mRDT (r = 0.12, P = 0.9; χ 2= 38, df = 2 and P = 0.49). CONCLUSION: These findings suggest that training of stakeholders in malaria control improves diagnosis and treatment of malaria. However, a broader scope of training in other settings may be required for an effective malaria control in Nigeria.

Assessment of competence of participants before and after 7-day intensive malaria microscopy training courses in Nigeria.

Background: The accuracy of malaria diagnosis by microscopy has been a challenge in health facilities in Nigeria due to poor competence of microscopists and inability to report on malaria species other than Plasmodium falciparum. Short microscopy courses were conducted to improve the skills of laboratory personnel to perform malaria microscopy in public health facilities in Nigeria. Materials and Methods: Seven-day malaria microscopy courses were conducted annually between 2011 and 2013 for microscopists in public health facilities. The training courses contained theoretical and practical sessions. Impact of the training was evaluated by practical and theoretical pre- and post-training assessments on malaria slide reading, parasite enumeration and basic malariology. Results: The 102 participants who completed the training consisted of medical laboratory scientists (62; 60.8%), medical laboratory technicians (24; 23.5%) and other healthcare workers (16; 15.7%). The knowledge of basic malariology (theory) at pre- and post-tests were 34% (95% CI 31.7-36.3%) and 74.9% (95% CI 71.8-78.0%), respectively (P<0.001). The mean slide reading detection, species and counting agreements in pre-training assessment were 48.9%, 27.9% and 0%, respectively, and in post-training 56.8%, 39.2% and 25%, respectively. The mean species agreements in picture test pre- and post-training were 21.9% and 55.1%, respectively. There were significant differences (P<0.05) in the median pre-test scores in picture tests and basic malariology of the three categories of participants but not in malaria slide reading and parasite counting tests. However, post-training, a significant difference in test scores of the three categories of participants was recorded only for basic malariology (P=0.0003). Conclusions: The 7-day malaria microscopy courses significantly increased the knowledge and microscopy skills of the trainees and were sufficient to bridge the significant difference in baseline microscopy skills of the different categories of trainees that participated in the training courses.

Persistence of markers of chloroquine resistance among P. falciparum isolates recovered from two Nigerian communities.

Background: A recovery in chloroquine efficacy following a period of cessation has raised the possibility of its reintroduction for malaria chemotherapy. We investigated the prevalence of the major markers of chloroquine resistance years after the withdrawal of the drug in Nigeria. Materials and Methods: Finger prick blood samples were collected from participants presenting with symptoms of malaria in two selected health centres each representing Lekki and Ijede communities of Lagos, Nigeria. Thick and thin blood smears were prepared for microscopy and dry blood spots made from malaria-positive participants for parasite DNA extraction. The detection of mutations in the Plasmodium falciparum chloroquine resistance transporter (pfcrt) and P. falciparum multidrug resistance (pfmdr1) genes was performed by nested polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP). Results: Of the 1527 blood samples that were confirmed by PCR to be P. falciparum positive, 412 and 344 were typed for the molecular detection of pfcrt and pfmdr1 gene mutations, respectively. The mutant alleles of pfcrt were present among 290 (70%) parasite carriers while the pfmdr1 mutant allele was found in 117 (34%) of the total population. There were higher distributions of the mutant alleles for the two loci in Ijede than in Lekki. The observed frequencies of pfcrt mutant alleles in the two parasite populations were in agreement with the expected frequencies predicted by Hardy-Weinberg. In comparing data with studies conducted between 2000 and 2002 in Ijede, we observed an increase in the prevalence of mutant type pfcrt against a marginal decline in the pfmdr1 mutant type. Conclusion: The high frequencies of pfcrt mutation are suggestive of a persistent drug pressure and continuing inefficacy of chloroquine as an antimalarial drug.