Chorangiosis Implicated in Pregnant Women Infected with Malaria

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A passing remark launched the project that will be described at the Experimental Biology 2013 conference in Boston on Monday. A poster, presented by undergraduate Ashley McMichael from Albany State University, has preliminary data that hint that there is an association between a rare pregnancy condition and malaria.

The remark that launched the project was made by a collaborator of Julie Moore, a malaria expert at the University of Georgia. Moore was visiting her collaborator, pediatric pathologist Carlos Abramowsky at Children’s Healthcare of Atlanta (affiliated with Emory University), armed with placental tissue slides collected from women living in western Kenya, a region where malaria is rampant. While viewing the slides, Moore recalls Abramowsky commenting, “Wow, this is a really interesting case of chorangiosis.” And her reaction was, “Oh, what is chorangiosis?” [Read more…]

Malaria Prophylaxis and Getting Pregnant

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QUESTION

I will be traveling to the Ivory Coast for two weeks. I will be staying with my in-laws in the city in very clean conditions with a/c etc. I am a strict vegetarian so I will be bringing most of my food and will have access to clean water. I myself grew up in an undeveloped nation so I am used to precautions needed to prevent illness. However, mosquitoes do seem to love to bite me.

I sadly just had a miscarriage and want to try to conceive again within the next month. My doctor has prescribed Atovaquone-Proguanil for me. I am concerned about taking the drug since my body is recovering and as I said I want to try to conceive upon returning. How long will this drug stay in my system? Does it effect fertility or a fetus? Do the benefits outweigh the risks? How likely it is that I wouldn’t show signs of malaria until much later after potentially conceiving? I am also concerned of the emotional side effects of the medicine coupled with my recent loss.

Thank you for any information.

ANSWER

Firstly I am very sorry for your loss.    Your doctor prescribed Atovaquone-Proguanil  which is a first class  drug to prevent malaria.  Some people do experience  side effects but many do not. It is recommended to take the pill at the same time each day and with food or a milky drink.  Start taking the drug 1-2 days before you arrive and continue for a week afterwards. The drug should be out of your system within a few days after stopping it. Don’t try to conceive until after that.  While I do not know how long ago you had the miscarriage, WHO and UNICEF recommend waiting around 6 months before trying again, so that your body (and emotions) can recover fully.

Besides taking Atovaquone-Proguanil, be sure to protect yourself from mosquito bites; protect you legs and arms by wearing long sleeves and trousers/long skirt, avoid being out during dawn and dusk when mosquitoes like to feed, use an insect repellent (you can try citronella if you are worried about chemicals), and if the house isn’t screened (or even if it is), sleep under a long acting insecticide treated bed net.   Enjoy your trip and take care.

At what age can you get malaria?

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QUESTION

What age do you get malaria?

ANSWER

Malaria is transmitted by the bite of an infected mosquito, and therefore any one living  where malaria is present, at any age,  is susceptible. To prevent malaria,  sleep under a long-lasting insecticide treated bednet; make sure it is re-dipped in insecticide every year or so to maintain its efficacy. The mosquitoes which transmit malaria tend to feed at night, and so protecting yourself and your home during the evening, night and early morning is crucial. Maintaining good screens on all windows and doors can be a very effective way of preventing mosquitoes from entering, and in many parts of the world, people spray inside with insecticides to reduce the number of mosquitoes yet further. Wearing long-sleeved clothing at night and in the evenings can also prevent bites.

Pregnant women though, due to changes to the mother’s immune system and also perhaps due to the physiology of the placenta, are very vulnerable to malaria. There is also the risk (up to 33% in some studies) that malaria will pass directly from the mother to the baby, either through the placenta or in blood during childbirth—this is called “congenital malaria,” and can manifest as early as 1 day after delivery but a late as months after. The symptoms are similar to that of adult malaria, with fever, anaemia, lethargy, etc.

Even if the unborn baby does not get congenital malaria, it can be effected by its mother having malaria during pregnancy, with possible low birth weight, anaemia and even spontaneous abortion—abortion rates due to malaria can vary between 15-70%.

Given these negative effects, it is very important to protect pregnant women against malaria, and bednet distribution schemes in many places target these women. In high transmission settings, women may also be offered intermittent preventive therapy (IPT) which consists of at least two doses of anti-malarial medication, usually once during the second and once during the third trimester.

Malaria Prevention During Pregnancy

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QUESTION

I am emigrating (moving permanently) to Mozambique – Vilanculos in October after my marriage, I want to fall pregnant.

What medicine can I take to prevent malaria during my pregnancy in Mozambique? I am afraid of getting malaria while I am pregnant. I am from South Africa, will the doctors here have a remedy for me to take before I am moving to Vilanculos? Do you know of any malaria prevention during pregnancy medicine?

ANSWER

Certain drugs commonly used to prevent malaria are not appropriate for
pregnant women. Those which can be taken by pregnant women are
chloroquine and mefloquine (the latter is commonly sold as Lariam).
Unfortunately, the type of malaria found in Mozambique is resistant to
chloroquine, and so this drug is not recommended for people living in
this area. As such, mefloquine remains as the likely first choice
preventive drug for you when you get pregnant. Some studies suggest
mefloquine should not be taken in the first trimester of pregnancy,
but in high malaria transmission zones, the dangers of malaria may
outweigh these early risks. You can talk to your doctor about the pros
and cons of this. There are also no problems with taking it long term
(i.e. for the 9 months of pregnancy), and the Centers of Disease
Control in the US also state it is safe for infants to consume small
amounts of mefloquine, so it can be taken during breast feeding as
well. It is important to note that mefloquine is not recommended for
people with a history of certain psychiatric disorders, so you should
consult with your doctor before taking it if you have a history of
mental illness.

Throughout your pregnancy, you should also be aware of other methods
for preventing malaria, such as sleeping under a long-lasting
insecticide treated bednet, and making sure your house is fully
screened to prevent mosquitoes from entering. Wearing long sleeved
clothing in the evening and at night when you’re outside, and insect
repellent on exposed skin, can also help prevent mosquito bites.

Malaria in Vietnam, Thailand, Bali

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QUESTION:

I am 5 months pregnant and I was thinking about going on holiday to Vietnam, Thailand, or Bali. What is the risk of malaria in this countries?

 

RESPONSE:

Malaria transmission occurs in all of the nations you mention, though certain areas within these nations are lower risk.

You can find out more about specific regions and local antimalarial resistance patterns at the CDC website.

You should certainly consult your prenatal doctor to discuss the variety of potential risks, in addition to malaria, associated with international travel in the developing world as you enter the third trimester of pregnancy. Malaria infection in pregnant women can be more severe than in nonpregnant women and can increase the risk for adverse pregnancy outcomes. For these reasons, and because no chemoprophylactic regimen is completely effective, women who are pregnant are usually advised to avoid travel to areas with malaria transmission if possible. If travel to a malarious area cannot be deferred, chemoprophylaxis is essential. Chloroquine containing medications are have not been found to have harmful effects on the fetus. For pregnant women travelling to areas where chloroquine resistance is present, mefloquine is usually recommended.

 

 

Malaria Infection

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QUESTION

How can you get infected with malaria?

ANSWER

Malaria is transmitted directly via the bite of an infected mosquito. Only certain female mosquitoes, of the genus Anopheles, can carry malaria. The mosquito picks up the malaria parasite (there are five different types of malaria that infect humans, though all are transmitted in exactly the same way) when it feeds on the blood of an infected person. The parasite then undergoes a cycle of reproduction in the mosquito, before new parasites migrate once again to the mosquitoes salivary glands. From here, they are able to escape into the blood of a new human host when the mosquito takes another blood meal by biting the person.

Since malaria is transmitted by blood, there have been a some reports of malaria transmission via organ donor or blood transfusion, though most countries now screen for malaria before using donated blood or organs. Additionally, if a pregnant woman gets malaria, the parasite can be passed to her baby either across the placenta or during delivery; this is called “congenital malaria”, and can be quite harmful to the baby. As such, and also because pregnant women themselves are especially vulnerable to malaria, many campaigns have dedicated themselves to providing pregnant women with long-lasting insecticide treated bednets and other measures to prevent and treat malaria.

Malaria Treatment While Pregnant?

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QUESTION:

1) I am two months pregnant. Please, what drug can I use to treat malaria? 2) How often should I treat malaria?

ANSWER:

The specific answer to your question depends a bit on whether you believe you are already actively infected with malaria (in other words, you are feeling ill right now, or have done recently) or if you would like information on preventing malaria during your pregnancy.

In both cases, there are certain drugs which have been tested as safe for pregnant women, but whether these drugs are appropriate for you depends on where you live, what types of malaria you might have been exposed to, and, as I mentioned first, whether you are seeking treatment for an existing episode of malaria or want to prevent future illness.

I have asked one of our board members, who is an expert on maternal health and pregnancy, to comment further, so please check back here soon!

Traveling and Pregnant

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QUESTION:

Hi, I am 3 months pregnant but thinking about going on vacation to Belize in a few weeks time. Should I think about taking something against malaria?

ANSWER:

It’s good you asked because getting malaria while pregnant can be much more serious than when not pregnant, and can cause terrible problems to both you and your baby.  Therefore, it is always advisable to consult your own health care provider before traveling.

The good news is that while there is malaria in Belize it is not found everywhere and where it is found, it is not resistant to chloroquine, a drug considered safe to use during pregnancy.

According to the US Centers for Disease Control (CDC),   Belize City and the islands where tourists mostly visit are largely malaria free, and the risk of getting malaria in these areas is ‘low’. So, if you are heading to Belize City or a resort on one of the islands, you may just want to follow practical advice to avoid mosquito bites: sleep in a screened room and under an insecticide treated bed-net, avoid being outside between dusk and dawn, and if you are, wear long-sleeves and long pants or skirt, and use mosquito repellent (containing DEET, and especially during pregnancy, in my opinion a  roll-on repellent if preferable to a spray to avoid inhaling the chemicals).

However, if you are heading off the beaten track, you should take all the mosquito bite precautions mentioned above but also take chloroquine as prophylaxis. Take chloroquine (500 mg tablet containing 300 mg base drug) one time a week starting 1 – 2 weeks before traveling to an area with malaria. Continue taking one pill once a week (on the same day and the same time) while in country and for another 4 weeks after leaving the malaria area.

 

Malaria Prevention

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Photo by Matthew Naythons, MD

Malaria prevention consists of a combination of mosquito avoidance measures and chemoprophylaxis. Although very efficacious, none of the recommended interventions are 100% effective.

Mosquito Avoidance Measures

  • Because of the nocturnal feeding habits of Anopheles mosquitoes, malaria transmission occurs primarily between dusk and dawn.
  • Contact with mosquitoes can be reduced by remaining in well-screened areas, using mosquito bed nets (preferably insecticide-treated nets), using a pyrethroid-containing flying-insect spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body.
  • All travelers should use an effective mosquito repellent. [Read more…]

Soil-Transmitted Helminths and Malaria in Pregnant Women on the Thai-Burmese Border

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Background: Deworming is recommended by the WHO in girls and pregnant and lactating women to reduce anaemia in areas where hookworm and anaemia are common. There is conflicting evidence on the harm and the benefits of intestinal geohelminth infections on the incidence and severity of malaria, and consequently on the risks and benefits of deworming in malaria affected populations. We examined the association between geohelminths and malaria in pregnancy on the Thai-Burmese border.

Methodology: Routine antenatal care (ANC) included active detection of malaria (weekly blood smear) and anaemia (second weekly haematocrit) and systematic reporting of birth outcomes. In 1996 stool samples were collected in cross sectional surveys from women attending the ANCs. This was repeated in 2007 when malaria incidence had reduced considerably. The relationship between geohelminth infection and the progress and outcome of pregnancy was assessed.

Principal Findings: Stool sample examination (339 in 1996, 490 in 2007) detected a high prevalence of geohelminths 70% (578/829), including hookworm (42.8% (355)), A. lumbricoides (34.4% (285)) and T.trichuria (31.4% (250)) alone or in combination. A lower proportion of women (829) had mild (21.8% (181)) or severe (0.2% (2)) anaemia, or malaria 22.4% (186) (P.vivax monoinfection 53.3% (101/186)). A. lumbricoides infection was associated with a significantly decreased risk of malaria (any species) (AOR: 0.43, 95% CI: 0.23–0.84) and P.vivax malaria (AOR: 0.29, 95% CI: 0.11–0.79) whereas hookworm infection was associated with an increased risk of malaria (any species) (AOR: 1.66, 95% CI: 1.06–2.60) and anaemia (AOR: 2.41, 95% CI: 1.18–4.93). Hookworm was also associated with low birth weight (AOR: 1.81, 95% CI: 1.02–3.23).

Conclusions / Significance: A. lumbricoides and hookworm appear to have contrary associations with malaria in pregnancy.

Author Summary: Intestinal worms, particularly hookworm and whipworm, can cause anaemia, which is harmful for pregnant women. The WHO recommends deworming in pregnancy in areas where hookworm infections are frequent. Some studies indicate that coinfection with worms and malaria adversely affects pregnancy whereas other studies have shown that coinfection with worms might reduce the severity of malaria. On the Thai-Burmese border malaria in pregnancy has been an important cause of maternal death. We examined the relationship between intestinal helminth infections in pregnant women and their malaria risk in our antenatal care units. In total 70% of pregnant women had worm infections, mostly hookworm, but also roundworm and whipworm; hookworm was associated with mild anaemia although ova counts were not high. Women infected with hookworm had more malaria and their babies had a lower birth weight than women without hookworm. In contrast women with roundworm infections had the lowest rates of malaria in pregnancy. Deworming eliminates all worms. In this area it is unclear whether mass deworming would be beneficial.

Citation: Boel M, Carrara VI, Rijken M, Proux S, Nacher M, et al. (2010) Complex Interactions between Soil-Transmitted Helminths and Malaria in Pregnant Women on the Thai-Burmese Border. PLoS Negl Trop Dis 4(11): e887. doi:10.1371/journal.pntd.0000887

Editor: Simon Brooker, London School of Hygiene & Tropical Medicine, United Kingdom

Copyright: © 2010 Boel et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This study was part of the Wellcome Trust Mahidol University Oxford Tropical Medicine Research Programme funded by the Wellcome Trust of Great Britain. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

More information: Full text: Complex Interactions between Soil-Transmitted Helminths and Malaria in Pregnant Women on the Thai-Burmese Border (PDF)