The Prevalence Of Malaria Among Pregnant Women On Admission In Imo State Specialist Hospital Owerri
The Prevalence Of Malaria Among Pregnant Women On Admission In Imo State Specialist Hospital Owerri
Abstract
A study was made to determine the prevalence of malaria infection among pregnant women on admission in Imo State specialist Hospital Owerri between July to August 2012. Blood samples were collected from the patients and a thick blood film made. The films were stained using parasitological standard procedures. Twenty-five (25) pregnant women in their 1st trimesters had the highest severe parasitaemia with 54.5%. And also primigravidae were also observed to have the highest infection rate with 87.5%. Similarly, the direct stained smear technique showed that 2,301 (80.1%) persons had malaria parasites while the Plasmodium falciparium (pf) antigen test showed that 1,801 (62.7%) persons were positive for malaria due to Plasmodium falciparium. Comparatively, the QBC and slide smear techniques were more effective for parasite detection than the pf antigen test. The age related prevalence showed that pregnant women within the age bracket 18 – 25 years had the highest prevalence (86.1%) of malaria infection, followed by those in the 36 – 40 (82.8%). The least prevalent age group was the 40 years and above group (74.7%) The overall mean infection according to zones showed that Owerri had the highest prevalence (83.9%), followed by Okigwe (72.1%) and Orlu (66.9%). Statistical analysis of the data showed a significant difference (p < 0.05) in the prevalence of plasmodiasis between the three zones of Imo State. Many pregnant women lost their jobs, some could not attend fully their businesses, some missed their religious activities due to malaria in pregnancy. Some women had low birth weight babies, some pre – term delivery etc due to malaria in pregnancy. This study has shown that malaria is a major public health challenge among pregnant women in Imo State Nigeria, leading to inestimable economic and social losses.
Chapter One
Introduction
Malaria is an infections disease caused by a parasite, plasmodium which infects red blood cells. Historical records suggest that malaria has infected human since the beginning of mankind. The name “mal aria” (Meaning bad air in Italian) was first used in English in 1740 by H. Walpole when describing the disease. The term was shortened to malaria in 20th century. Laveran; in 1880 was the first to identify parasites in human blood. In 1889, Ross discovered that mosquitoes transmit malaria.
Malaria continues to be a cause of great suffering in tropical and sub-tropical regions of the world (Brabin, 1989). Currently, it is endemic in about 100 countries affecting 4% of world’s population. Malaria has been eliminated or effectively suppressed in several parts of the world in past decade but is now undergoing resurgence (Gilles, 1987). It is returning to areas from which it had been eradicated as well as spreading into new areas such as central Asia and Eastern Europe. Despite global economic development people are dying from malaria now than 30 years ago.
Epidemiology and Clinical Features
Malaria in pregnancy remain a notable cause of maternal and prenatal morbidity and mortality, often associated with maternal illness, maternal anemia, low birth weight, preterm delivery and prenatal loss especially in the primigravidae. In semi-immune pregnant women, malaria infection may be asymptomatic, pregnant women are at risk of clinical disease compared to non-pregnant women at all levels of endemicity (Harrison, 1995). There is unparasitized blood cells leading to a greater level of anemia than can be explained on the basis of RBCS parasitization alone (who,1991).
Primgravidity is a known risk factor in pregnancy. It only becomes more prevalent in primigravide but also intense (Jimoh, 2003). The peak prevalence of parasitemia will be altered by prior anti malaria injection. In a study from Madan, Papua New Guinea, the peak prevalence in primigravidae studied reached 55% to compared to 86% in other study from Kenya (flemming, 1986). Studies have also suggested that the highest prevalence of infection occurs in the 2nd trimester with inflection rate at delivery and in the postnatal period approximating to levels in non pregnant women possibly due to immunity boosting during pregnancy (Akindele, et al 1993)
Causative Agent of Malaria
Malaria is caused by five (5) species of plasmodium. They are as follows:
Plasmodium vivax (p. vivax)
This species is milder and generally not fatal. However, infected people still need treatment because their untreated progress can also cause a host of health problems. (Rogreson et al 2007)
Plasmodium Malariae ( P. Malaria)
This species also is milder and not fatal. The infected person should be properly treated to avoid further health problems. This species is known to stay in the blood of the affected for several years (WHO, 2008).
Plasmodium Ovale (P. Ovale)
It is also mild and as well need adequate treatment to avoid serious health condition. It stays in the liver of the affected person even for years without symptoms. (Neeru, 2005)
Plasmodium Falciparum (P. Falciparum)
This is the most serious form of the disease. It is most common in Africa, especially sub-saharan Africa. It needed thorough and adequate treatment of the affected person (Okwa, 2003).
Plasmodium knowlesi (P. Knowlesi). This causes malaria in macaques but can also infect humans.
Incubation Period of Plasmodium
This refers to how long it takes from initial infection to the appearance of symptoms. This generally depends on the type (species) of parasite.
- P. falicparum – 9 to 14 days
- P. Vivax – 12 to 18 days
- P. vivax – 12 to 18 days
- P. malaria – 18-40 days
However, incubation periods can vary from as little as 7 days to several months for P. vivax and p. ovale
Signs and Symptoms
The signs and symptoms of malaria typically begin 8-25 days following infections. However, symptoms may occur later in those who have taken antimalaria medication as prevention. The signs and symptoms may include the following
- Fever
- Shivering
- Joint pain (Arthralgia)
- Vomiting
- Hemolytic anemia
- Jaundice
- Convulsion
- Sudden coldness followed by rigor
- Severe headache
- Enlarged spleen etc.
Life Cycle
The life cycle malaria is complex with asexual reproduction in the mammalian host and sexual reproduction in the anophelene vector. The female anopheles mosquito carrying malaria causing-parasites feeds on a human and injects the parasite in the form of sporozoites into the blood stream. The sporozoites travel to the liver and invade the liver. Within some days (5-6) the sporozites grow, divide and produce tens of thousands of merozoites. Some malaria parasite species remain dormant for extended periods in the liver. The merozoties exit the liver cells and re-enter blood stream to invade the red blood cell, it under goes asexual replication and release new formed merozoites from the red blood cells. Some of the merozoites infected blood cells instead of replicating asexually, develop into sexual forms of the parasite called male and female gametocytes that circulate in the blood stream.
When the mosquito has a blood meal, it ingests the gametocytes. In the gut, the infected human blood cell burst, releasing the gametocytes, which develop further into mature sex cell called gametes. Male and female gametes fuse to form ookinetes which burrow into the mosquito midgut and form outcasts. Growth and division of each oocyst produce thousands of active haploid forms called sporozoites which migrates to the salivary gland of the mosquito waiting for another round of blood meal (Ter kulie et al 2003)
Pathogenesis
During the life cycle of malaria parasites in human body, Mosquito infects a person by taking a blood meal. Initially, sporozoite enters the blood stream and migrate to the liver. They infect liver cells (hepatocytes); where they multiply into merozoites, rupture the liver cells and escape back into the blood stream. Then, the merozoites infect red blood cells, where they develop into ring forms, trophozoites and schizonts which in turn produce further merozoites. Sexual forms (gametocytes) are also produced, which if taken up by a mosquito, will infect the host and continue the life cycle. Malaria develop into too phases- exoerythrocytic and erythrocytic cycle/phases. Exoerythrocytic has to do with infection of hepatic or liver cells while erythrocytic phase entails infection of erythrocytes or red blood cell, the sporozite migrates to the liver and infects the hepatocytes. It can continue to multiply without showing any symptoms within 8-30 days (cogsnell, 1992).
Effect of Malaria Infection in Pregnancy
There are many adverse effects of malaria during pregnancy. Pregnant woman are known to be more prone to contracting malaria than those that are not pregnant. A women’s immune system is affected during pregnancy. He becomes much more susceptible to developing malaria which atime even leads to death of the child before birth or right after delivery (Steketee, et al, 2001). Some adverse effects of malaria during pregnancy include:-
- Anemia (Maternal and foetal aneinia)
- Fever
- Altered blood sugar levels
- Infection that harms the genitals
- Chance of cerebral malaria or other neurological problems
- Miscarriages
- Still birth
Treatment / Management of Malaria in Pregnancy
Treatment of malaria in pregnancy differs from the treatment of same woman outside pregnancy in several respects. Frequency and severity of infections are more in pregnancy particularly among primigravidae (Mutabingwa, 2004). Pregnant women with malaria infection must be treated both medically and obstetrically, taking care of both maternal and fetal interests. It is reasonable to expect confirmation of malaria infection in pregnancy. The choice of a suitable drug is predicated upon many factors including gestational age of fetus severity of the disease, the resistance of the infecting malaria parasites to the anti malaria drugs and safety profile of the drug in both mother and fetus. Ideally, effective care should clear both peripheral and placental parasites (Lars Hived, 1998).
Obstetric Management of Pregnant Women with Malaria Infection
Obstetric management is an integral part of the complete management of the malarious pregnant women. It consists of antepartum, intrapartum and post partum care.
Antepartum Care of Pregnant Women with Malaria
Essentially, during the antepartum or prenatal period, the antenatal clinic forms the template upon which the institutional treatment is based. As part of the routine ante natal care, history of malaria is obtained, blood tests including full blood count and malaria parasites are routinely requested for. Regular antenatal is of great importance as a single missed monthly clinic visit can result in a two fold increase malaria incidence. (Garnier, 1994) .
Intra Partum Management of Malariain Pregnancy
Intra partum management of parturient malarious women should include treatment of acute malaria with suitable agent. Routine intrapartum haemoglobin check is mandatory as ongoing hemolytic or pre-existing maternal anemia can substantially affect maternal and fetal outcome (Shulman et al, 1999).
Postpartum Management of Malaria in Pregnancy
Following delivery, the mother should complete her antimalarials and supportive treatment. The foetus should be properly examined and congenital malaria excluded. The foetus should be properly examined and congenital malaria excluded. The newborn’s peripheral venous blood should be done to check for malaria parasites.
Experiences by many authors have shown that heavy maternal parasitaemia significantly increases placental parasitization and fetal parasitaemia with consequent fetal anemia and possible fetal demise (Parise etal, 1998). The use of malaria vaccine in both the mother and the fetus postpartum is still inconclusive and controversial and many trials are underway to ascertain their safety profile and effectiveness.
Prevention / Control of Malaria in Pregnancy
The main ways of preventing malaria in pregnancy can be achieved in two ways, they are;
Avoiding mosquito bite:- This can be achieved in various ways.
A) Vector Control:
This means trying to reduce contact with the vector of the disease. Controlling mosquito can significantly reduce malaria incidence as well as other mosquito borne diseases. Installation of screened windows air condition together with strategies to reduce vector populations are very effective and have led to the total elimination of malaria without completely getting rid of the mosquito (Neeru, 2005).
B) Use of Insecticide Treated Bed Nets (ITNS):
ITNS can reduce the incidence of malaria infection in pregnancy and also mortality rate in endemic areas. If ITNS are widely used in an endemic places, the mosquito population may drop dramatically as well as their life spans.
2) Preventing Disease Using Anti Malarial Medications:
Drugs that are effective and at the same time that cannot affect the growing foetus should be administered starting from early pregnancy. This type of prevention is also known as suppression, they do not prevent the parasite from entering the blood stream but they stop it from developing in the blood (mc cormick,1985)
Literature Review
According to Oxford Medical Dictionary, pregnancy is a period during which a woman harbors a developing foetus normally in the uterus. This last for approximately 266 days from the time of conception till the time of delivery the baby 280 days from the first day of a woman’s menstrual period.
It has been observed that malaria in pregnancy has continued to be a scourge in tropical and subtropical region of the world. However, p. Falciparum has been noted to be the most serious form of the disease in pregnancy. (WHO, 1993).
Malaria in pregnancy is the major cause of stillbirths, infant mortality, maternal mortality and even low birth weight (Menendez, 1994). In areas where malaria is endemic, people may have immunity or semi – immunity and therefore have either no symptoms or few symptoms.
The severity of the malaria depends on three things:
- The type of parasite
- Ones immunity
- The functional ability of one’s spleen (Schultiz, 1994).
The parasite is transmitted by female anopheles mosquito when it bites human. As the parasite exists in human red blood cells, malaria can be passed from one person to the other through organ transplant, share of used needles/syringes and blood transfusion. Additionally, infected mother can as well transfer malaria to her baby during delivery it is called congenital malaria (Bray et al, 1999).
Objectives of the Study
This research work is made to find out the rate at which malaria affect pregnant women and their unborn children. It is also made to educate mothers of childbearing age and even the entire population on how best to check malaria infection in order to enhance the health of mother and child.
Chapter Four
Discussions
Malaria has been described as a major cause of morbidity and mortality in many tropical and subtropical countries (Forbes and Jackson, 1993). The number of cases imported from endemic areas grow each year as a result of ever increasing global travel. Increasing geographic spread of resistance of Plasmodium parasites to chloroquine and other antimalarial drugs is causing major problems in the management and control of the disease. Previous studies (Mashaal, 2000) reported that malaria consists of about 10 – 30% of all hospital admissions in malaria endemic areas. The high prevalence of malaria by QBC method (80.9%) observed amongst pregnant women in this study agrees with similar report by Ngele, (2008), who obtained a 72% prevalence amongst pregnant women attending ante – natal care at secondary health facility in Ebonyi State Nigeria. The slight variation in the two reports may be attributed to the difference in the diagnostic methods used. While the present study used pf antigen test, stained smear microscopy and QBC methods, Ngele (2008) used only the stained smear microscopy method. Furthermore, Ngele (2008) studied pregnant women in a secondary health facility only whereas the present study was carried out in three zones of Imo State, covering two tertiary and one secondary health facilities with a population size 10 times more than that of Ngele (2008). However, both studies emphasized the public health importance of malaria in the tropics. Furthermore, the studies show that malaria is a major public health problem amongst pregnant women in Nigeria.
The age – related prevalence showed a decrease in infection with increase in age from 86.1% to 74.7% (QBC), 85.1% t0 71.9% (stained smear microscopy) and 77.5% to 47.9% (pf antigen test), with a mean of 82.7% to 64.8% amongst pregnant women in the age group 18 – 25 years and those in the 40 years and above age brackets. Statistically, this difference in prevalence in various age groups was not significant (p > 0.05). This observation agrees with the findings of previous workers (Bruce – Chwatt, 1980; Mashaal, 2000; Usip and Opara, 2008) who stated that age and sex have no bearing on the incidence of malaria. Bray and Anderson (1999) further added that the increase relative to non pregnant women remains fairly constant with age, however there is an overall decrease in prevalence and densities in both pregnant and non pregnant women with increase in age.
The prevalence of malaria in relation to zones in this study showed that Owerri was significantly higher (90.9%) than Okigwe (76.8%) and Orlu (72.0%) zones. This may reflect the more deteriorating environmental conditions of the urban city (Owerri) than the sub – urban areas of Okigwe and Orlu. The accumulation of refuse dumps and irregular disposal of municipal wastes as well as the blockages of gutters in Owerri serve as breeding sites for the vectors of malaria parasites. In Orlu, and Okigwe, the population is smaller with people living in more spacious environments and waste management constitutes little or no problem since most household have evolved effective ways of disposing their wastes regularly.
Malaria infection was highest (84.7%) amongst pregnant women in the second trimester of pregnancy, followed by those in the third and first trimesters (79.5%) and (77.5%) respectively. This finding corroborates the report of Mashaal, (2000) who observed that during the second half of pregnancy (2nd to 3rd trimesters), there is multifactorial transient immunosuppression. The presence of high adrenal steroid levels, placental chorionic gonadotrophin, alpha fetoproteins and the depression of the lymphocytes role, may play an important role in the immunosuppression mechanism of a pregnant female. Therefore malaria relapses of infection due to Plasmodium vivax, P. malariae, P. ovale or recrudescences of P. falciparium are frequently seen at a higher rate in pregnant women than in non pregnant women.
Pregnant women having a combination of headache and fever had the highest prevalence (96.8%) than those who have headache alone (94%) and those with fever alone (88.5%). The least prevalence (43.9%) was observed amongst those with general body weakness and followed by those without any manifest symptom (52.3%). This finding agrees with previous reports (Mashall, 2000; Forbes and Williams, 1981), who stated that features of an acute malarial attack may include fever, rigors, sweating, headache, myaglia, gastrointestinal upset and respiratory symptoms. In severe falciparium malaria, there may be collapse, convulsions and coma (cerebral malaria). Elsewhere, Chukwuocha et al., (2008) reported that fever, vomiting and headache were the most common clinical symptoms observed in 32.9% of their study participants. Other workers (Mashall, 2000; Forbes and Williams, 1981) reported that the presence of retinal haemorrhage in non – comatose patient often heralds the rapid onset of cerebral symptoms. Spleenomegally and anaemia are common in acute attacks. Acute haemolytic crises may also be associated with haemoglobiuria (blackwater fever). Chronic infection may be associated with massive spleenomegaly (tropical spleenomegaly syndrome) or with the nephritic syndrome.
The diagnostic methods used in this study showed that quantitative buffy coat centrifugal method (80.9%) and the direct blood smear technique (80.1%) was more sensitive in detection of malaria parasites than the pf antigen test (62.7%). This finding agrees with previous reports (Amadi et al., 2008), which observed that rapid malaria test based on soluble antigen detection gives significant false positive and false negative results and fails to detect low infection densities. Over the years, the thick blood film method has remained the predominant and acceptable malaria detection method worldwide. The thick – film method, which involves the microscopic examination of Giemsa stained dried blood films demands a degree of technical skill, training and experience. Understandably, these skills levels are rarely in adequate supply in regions devastated by malaria (Becton, 2006a). The thick
– film method requires that diagnosis be made in specialized laboratories with qualified laboratory scientists. Such laboratories are often located far from the village, where patients live. Slide preparation and interpretation are tedious and time consuming. Obscuring debris, poor contrast from inadequate staining and other random “noise” significantly reduce sensitivity. The delay between specimen collection and positive diagnosis can be from days to weeks and when positive cases of malaria are diagnosed, it is often impossible to find the patients and treat them because they have left the area or they are too sick to leave home or they have died. Consequently, malaria continues to spread. Millions of children, women and men continue to die annually. The limitations of the thick film method for detecting malaria have prompted the need for more effective, sensitive and reliable alternative. A more efficient, less technically demanding and more sensitive diagnostic method is required in order to reduce transmission rates, disease incidence and morbidity. Prompt and accurate diagnosis can lead to selective rather than presumptive use of anti – malarial drugs. Immediate diagnosis within the community will also allow for more selective and targeted insecticide use, conserving resources and minimizing the possibilities of resistance.
The QBC malaria test provides markedly increase levels of accuracy and sensitivity, simple to learn, potable and cost effective. It enables non – technical health workers to test large numbers of patients and rapidly diagnose early cases. The typical processing time for the thick film slide technique is 40 minutes for a batch of 25 slides. With QBC batches of 20 tubes can be centrifuged simultaneously (total time to collect and process QBC samples is 60 seconds per specimen).
Although the pf antigen technique appears to be less effective in the diagnosis of malaria, it is the simplest technique and requires no skill. The patient can do the test without consulting a laboratory scientist or technician. The test can be completed in a few seconds. The disadvantages are the high cost of kits presently in Nigeria and low sensitivity of the test leading to false negative results especially in cases of low parasitaemia.
The socio – economic consequences of malaria are many. In the present study, about 25.2% failed in their religious obligations, while 20.8% failed or missed social activities or engagements. Another 31.1% failed in their domestic obligations due to malaria. Economically, the women lost about N3,364,000. 00 and N2,447,500. 00 within 6 months, for treatment of malaria and expected revenue lost due to malaria respectively. In addition to these are other unestimated expenses incurred, such as cost of transport while seeking treatment, funeral expenses for children and adults who die as a result of malaria, aerosol sprays, mosquito coils, mosquito nets and other mosquito control expenses. It is estimated that 40% of health facility expenditures in sub-Saharan Africa are spent on malaria treatment. In industry and agricultural enterprises like livestock and crop farms, malaria accounts for the greatest number of man – hour lost, which may be up to or more than 50% of all the man – hours lost. This affects production and revenue for the industry, families and the nation as well. There is loss of investment funds thus affecting the economy of the nation. It is known that investors are not much interested in investing in countries where most of their profits will be lost through absenteeism from work due to malaria and on treatment of malaria infected workforce.
Malaria has serious socio – cultural consequences on families by causing absenteeism from school and thus affecting academic performance and loss of investment funds thus affecting the economy of Nigeria. Malaria has caused many people to fail in their religious obligations, marriage and domestic duties, etc. while it is known that investors are not much interested in investing in countries where most of their profits will be eroded through absenteeism from work. It can hardly be estimated how much this country loses through potential investors who dread malaria and its impact on the workforce.
Conclusions
This study showed that malaria is endemic amongst pregnant women in the State and amongst the Imo populace in general. The data available from the State Ministry of Health showed increase in the prevalence of malaria amongst Imo populace and pregnant women in particular. From 2012 to 2013, the prevalence of malaria increased by 65% and dropped in 2014 but rose again from 2014 to 2015 by 104% with a slight drop in 2016 but rose again from 2015 to 2017 by 2.1%. One obvious fact from the available data is that malaria has remained endemic and increases at a very high rate in Imo State over the years. This finding corroborates the report of previous workers (Nwokeocha, 2004) who reported increasing prevalence of malaria amongst children in Imo State. The increasing prevalence of malaria in Imo over the years may be related to deteriorating environment and poor sanitary condition prevalent in Imo State for over a decade now.
Recommendations
From our present day study, we recommend that further research tools be carried out on other antimalarial drug such as sulfadoxine- pyrimethamine, proguanil, within the study area to provide a good surveillance data on antimalarial drug resistance that/which provide stakeholders, involve in malaria control programme arrive at valuable strategies and policies in curtailing drug resistance menace. Also update in surveillance data will help to improve effective control strategies that will prevent a new gene pool of the vector (Anopheles gambiae) thereby resulting in inefficacy of the anti malarial drugs and insecticides.
This study also recommends that patients tested negative for malaria parasitaemia by standard microcopy, who still suffer re-surgencies of malaria fever be retested using both standard microscopy and Rapid Diagnostic Test. This is to prevent misdiagnosis and unnecessary treatment for malaria in many malaria suspected subjects.
Generally, presumptive rule diagnosis should be avoided to enable malaria suspected patient to undergo laboratory test before onset of treatment for malaria. This will help prevent emergence of antimalarial drug resistance resulting due to much exposure of the parasite to the drug leading to a selection under pressure whereby the parasite mutate to circumvent therapeutic effect of the drug.
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