Causal effects on low Apgar at 5-min and stillbirth in a malaria maternal-fetal health outcome investigation: a large perinatal surveillance study in the Brazilian Amazon.

BACKGROUND: Malaria elimination in Brazil poses several challenges, including the control of Plasmodium falciparum foci and the hidden burden of Plasmodium vivax in pregnancy. Maternal malaria and fetal health outcomes were investigated with a perinatal surveillance study in the municipality of Cruzeiro do Sul, Acre state, Brazilian Amazon. The research questions are: what are the causal effects of low birth weight on low Apgar at 5-min and of perinatal anaemia on stillbirth? METHODS: From November 2018 to October 2019, pregnant women of ≥ 22 weeks or puerperal mothers, who delivered at the referral maternity hospital (Juruá Women and Children's Hospital), were recruited to participate in a malaria surveillance study. Clinical information was obtained from a questionnaire and abstracted from medical reports. Haemoglobin level and presence of malarial parasites were tested by haematology counter and light microscopy, respectively. Low Apgar at 5-min and stillbirth were the outcomes analysed in function of clinical data and epidemiologic risk factors for maternal malaria infection using both a model of additive and independent effects and a causal model with control of confounders and use of mediation. RESULTS: In total, 202 (7.2%; N = 2807) women had malaria during pregnancy. Nearly half of malaria infections during pregnancy (n = 94) were P. falciparum. A total of 27 women (1.03%; N = 2632) had perinatal malaria (19 P. vivax and 8 P. falciparum). Perinatal anaemia was demonstrated in 1144 women (41.2%; N = 2779) and low birth weight occurred in 212 newborns (3.1%; N = 2807). A total of 75 newborns (2.7%; N = 2807) had low (< 7) Apgar scores at 5-min., and stillbirth occurred in 23 instances (30.7%; n = 75). Low birth weight resulted in 7.1 higher odds of low Apgar at 5-min (OR = 7.05, 95% CI 3.86-12.88, p < 0.001) modulated by living in rural conditions, malaria during pregnancy, perinatal malaria, and perinatal anaemia. Stillbirth was associated with perinatal anaemia (OR = 2.56, 95% CI 1.02-6.42, p = 0.0444) modulated by living in rural conditions, falciparum malaria during pregnancy, perinatal malaria, and perinatal fever. CONCLUSIONS: While Brazil continues its path towards malaria elimination, the population still faces major structural problems, including substandard living conditions. Here malaria infections on pregnant women were observed having indirect effects on fetal outcomes, contributing to low Apgar at 5-min and stillbirth. Finally, the utility of employing multiple statistical analysis methods to validate consistent trends is vital to ensure optimal public health intervention designs.

Malaria congénita en un hospital de Iquitos, Perú / Congenital malaria in a hospital in Iquitos, Peru

Objetivos. Determinar la frecuencia y características clínicas de los recién nacidos con malaria congénita en el Hospital de Apoyo de Iquitos en la Amazonía peruana. Materiales y métodos. Estudio descriptivo, prospectivo y transversal. De enero de 2011 a diciembre de 2013 se estudiaron 14 017 recién nacidos y a sus madres, de quienes se seleccionaron 52 portadoras de malaria gestacional mientras que a sus recién nacidos se les hospitalizó en el Servicio de Neonatología del hospital, y fueron sometidos a evaluación clínica y estudios de laboratorio. Resultados. La frecuencia de malaria gestacional fue de 0,4% y una proporción de malaria congénita de 9,6%. Plasmodium vivax fue hallado en 80% de casos de malaria gestacional y en 60% de malaria congénita. Se observó un caso de óbito fetal con gota gruesa positiva para Plasmodium falciparum. El cuadro clínico en recién nacidos fue fiebre, hipoactividad, irritabilidad y pobre succión. Conclusiones. Se documenta la presencia de malaria congénita en recién nacidos de madres con malaria gestacional. El cuadro clínico se asemeja a una sepsis neonatal. El diagnóstico precoz de malaria congénita y el tratamiento oportuno cursan con buena evolución.

Objectives. To determine the frequency and clinical features of newborns with congenital malaria in the Hospital de Apoyo of Iquitos in the Peruvian Amazon. Materials and methods. Descriptive, prospective and cross-sectional study. From January 2011 to December 2013, 14.017 newborns and their mothers were studied, of whom 52 carriers of gestational malaria were selected while their infants were hospitalized in the Neonatology Unit, and underwent clinical assessment and laboratory studies. Results. Gestational malaria frequency was 0.4% and a proportion of 9.6% of congenital malaria. Plasmodium vivax was found in 80% of cases of gestational malaria and in 60% of congenital malaria. A case of fetal death with positive thick blood smear for Plasmodium falciparum was observed. The clinical presentation in newborns was fever, hypoactivity, irritability and poor suction. Conclusions. The presence of congenital malaria in infants born to mothers with gestational malaria is documented. The clinical picture resembled neonatal sepsis. Early diagnosis of congenital malaria and timely treatment present with good evolution.

Sentinel network for monitoring in vitro susceptibility of Plasmodium falciparum to antimalarial drugs in Colombia: a proof of concept

Drug resistance is one of the principal obstacles blocking worldwide malaria control. In Colombia, malaria remains a major public health concern and drug-resistant parasites have been reported. In vitro drug susceptibility assays are a useful tool for monitoring the emergence and spread of drug-resistant Plasmodium falciparum. The present study was conducted as a proof of concept for an antimalarial drug resistance surveillance network based on in vitro susceptibility testing in Colombia. Sentinel laboratories were set up in three malaria endemic areas. The enzyme linked immunosorbent assay-histidine rich protein 2 and schizont maturation methods were used to assess the susceptibility of fresh P. falciparum isolates to six antimalarial drugs. This study demonstrates that an antimalarial drug resistance surveillance network based on in vitro methods is feasible in the field with the participation of a research institute, local health institutions and universities. It could also serve as a model for a regional surveillance network. Preliminary susceptibility results showed widespread chloroquine resistance, which was consistent with previous reports for the Pacific region. However, high susceptibility to dihydroartemisinin and lumefantrine compounds, currently used for treatment in the country, was also reported. The implementation process identified critical points and opportunities for the improvement of network sustainability strategies.