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 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.

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.

Efficacy, safety and tolerability of artesunate-mefloquine in the treatment of uncomplicated Plasmodium falciparum malaria in four geographic zones of Nigeria.

BACKGROUND: The combination of artesunate and mefloquine has been reported to be effective against multi-drug resistant Plasmodium falciparum malaria, which has been reported in Nigeria. The objective of this multi-centre study was to evaluate the efficacy, safety and tolerability of the co-packaged formulation of artesunate and mefloquine in the treatment of uncomplicated malaria in two weight groups: those between 15 - 29 kg and > or = 30 kg respectively. METHODS: The trial was conducted in rural communities in the north-east, north-central, south-west and south-eastern parts of Nigeria. The WHO protocol for testing antimalarial drugs was followed. Outpatients having amongst other criteria, parasite density of > or =1,000 microl were enrolled. The co-packaged drugs were administered for 3 days at a dosage of artesunate, 4 mg/kg body wt/day and mefloquine, 25 mg/kg/body wt total) on days 0, 1 and 2. Patients were followed up for 28 days with the assessment of the parasitological parameters on days 1, 2, 3, 7, and 28. RESULTS: Four hundred and forty-six (446) patients were enrolled and 431 completed the study. Cure rates in both treatment groups was >90% at day 28. The mean parasite clearance times in treatment groups I and II were 40.1 and 42.4 hours respectively. The combination of artesunate and mefloquine showed good gametocidal activity, (gametocyte clearance time of 42.0 & 45.6 hours in treatment groups I and II respectively). There were no serious adverse events. Other adverse events observed were headache, dizziness, vomiting and abdominal discomfort. There was no significant derangement in the haematological and biochemical parameters. CONCLUSION: This co-packaged formulation of artesunate + mefloquine (Artequin) is highly efficacious, safe and well-tolerated. It is recommended for the treatment of uncomplicated P. falciparum malaria in Nigeria.