Effectiveness of Intermittent Preventative Treatment with Sulfadoxine-Pyrimethamine During Pregnancy on Maternal and Infant Outcomes in Malawi Public

Zhang, Amy (Spring 2020)

Permanent URL: https://etd.library.emory.edu/concern/etds/bz60cx371?locale=fr
Published

Abstract

Malaria during pregnancy is associated with low birthweight and other adverse birth outcomes. Increasing drug resistance may undermine the efficacy of intermittent preventative treatment (IPTp) with sulfadoxine-pyrimethamine (SP). A cross-sectional study enrolled HIV-negative women at the time of delivery from July to October 2015 at two district hospitals in southern Malawi. The exposure of interest was the number of IPTp-SP doses received during pregnancy, coded as <3 vs ≥3 doses in primary analyses. The primary outcome was infant birthweight. Secondary outcomes included peripheral and placental malaria infection and a composite birth outcome indicator comprised of low birthweight, preterm birth, and small for gestational age. SP resistance markers were assessed by polymerase chain reaction (PCR). Of 536 women enrolled, 49% received <3 SP doses. Controlling for gravidity, average infant birthweight among women who received three or more SP doses was 91.4 g higher than that among women who received less than three doses of SP (p=0.02). The association between 3+ SP doses (versus <3) and peripheral infection was marginally protective (adjusted prevalence ratio=0.53, 95% CI: 0.28-1.03, p=0.06). Increasing number of SP doses was not statistically significantly associated with protection against placental malaria infection or the composite birth outcome. A total of 91 (17%) samples were PCR positive; 82 (90.1%) samples were successfully genotoyped. All harbored the A437G and K540E mutations associated with the quintuple mutant for SP resistance, which confers high level resistance; only two samples harbored the A581G mutation associated with the “super resistant” sextuple mutant. None of the samples harbored mutations at codons 436 or 613. IPTp-SP provides benefit to Malawian pregnant women and their infants, with a higher mean birthweight and less peripheral malaria among women who received three or more doses of SP, even in a setting of high SP drug resistance.  

Table of Contents

Chapter I: Background and Literature Review.................................................................1

     Malaria Epidemiology..................................................................................................1

     Malaria in Pregnancy (MiP).........................................................................................3

     Malaria in Malawi........................................................................................................4

     Policies for MiP Prevention in Malawi.........................................................................5

     Challenges to IPTp-SP................................................................................................. 5

Chapter II: Manuscript.....................................................................................................8

     Abstract........................................................................................................................8

     Introduction.................................................................................................................9

     Methods.......................................................................................................................11

     Results..........................................................................................................................15

     Discussion....................................................................................................................18

References........................................................................................................................22

Tables...............................................................................................................................29

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