Loretta Brabin

Parasitic Infections in Women and their Consequences

Publisher Summary This chapter focuses on the factors affecting immunity in both nonpregnant and pregnant women and on the chronicity of several infections that are carried through successive pregnancies with adverse consequences for mother and child. It considers risks to women of reproductive age to differ from men of equivalent years. Ensuring a reduction in the parasitic burden of women of reproductive age is the first step in reducing fetal infection and sensitization and in influencing the pathological pattern of parasitic disease in communities living in endemic areas. The practical and research implications of considering women as a special risk group for complications of parasitic infection are considerable and should lead to the development and implementation of improved control strategies. Health planners need to recognize that parasitic infection has serious consequences in pregnant women and primary health care services must be better equipped to detect and manage infections during pregnancy and between pregnancies. This chapter reviews those infections that are primarily identified by the Special Program for Research and Training in Tropical Diseases (World Health Organization) as being of particular public health concern (onchocerciasis, filariasis, schistosomiasis, malaria, African trypanosomiasis, and leishmaniases), although reference to other infections is made where relevant.

Improving antenatal care for pregnant adolescents in southern Malawi.

BACKGROUNDnThis paper considers why antenatal care (ANC) programs for adolescents may need to be improved in areas where a high proportion of first pregnancies are to young girls.nnnDESIGNnDescriptive data on the characteristics of 615 adolescents (aged 10-19 years) who attended for a first antenatal care visit at two rural hospitals in southern Malawi are given. For the 41.5% who came for a supervised delivery, details of their pregnancy care and delivery outcome are provided. The Chi-square test is used for determining significant differences between age and parity groups and logistic regression for an analysis of low birthweight.nnnRESULTSnFifty-two percent of girls were nulliparous, 24.5% were < or =16 years and 73.3% were illiterate. Prevalence of anemia, malaria and HIV infection was high. Girls who were nulliparous, illiterate, made early antenatal care visits or gave a history of stillbirth or abortion were less likely to attend for delivery. Few primiparae required an assisted vaginal delivery or cesarean section but primiparae had more adverse birth outcomes. Forty percent of primiparae <17 years gave birth to low birthweight babies as did 28.3% of multiparae. In a logistic regression (all adolescents) low birthweight was correlated with literacy (p=0.03) and number of antenatal care visits (p=0.01).nnnCONCLUSIONSnPregnancy morbidity and adverse birth outcomes were common in spite of antenatal care attendance. This partly reflects poor management of malaria during pregnancy. In areas like Malawi, where childbearing starts early, girls in their first pregnancy need good quality care and careful monitoring if problems are not to be perpetuated to a second pregnancy. Many girls start pregnancy with HIV and schistosomal infections which indicates the need for programs before girls become pregnant.

Reducing iron deficiency anaemia due to heavy menstrual blood loss in Nigerian rural adolescents

OBJECTIVEnMenstrual disorders are common in young women, and heavy menstrual blood losses (MBL) are an important cause of anaemia. Menstrual morbidity normally goes untreated in developing countries where cultural barriers also serve to mask the problems. We investigated the prevalence of menstrual morbidity, and measured MBL and its relationship to iron deficiency in a rural adolescent population. The rationale was to assess whether or not reducing heavy MBL could be part of a strategy to reduce iron deficiency anaemia.nnnSETTINGnRural village in south-east Nigeria.nnnDESIGNnCross-sectional survey.nnnSUBJECTSnThe study included all non-pregnant, unmarried nulliparous girls (< 20 years) who had menstruated, and who lived in KDere village.nnnMETHODSnA field worker allocated to each girl completed a questionnaire, and supervised recovery and collection of soiled pads and ensured blood sampling. MBL was measured using the standard alkaline haematin method. Haemoglobin (Hb), serum iron, transferrin saturation and protoporphyrin levels (ZPP) were also measured.nnnRESULTSn307 girls completed MBL measurements; 11.9% refused to participate. 12.1% had menorrhagia (> 80 ml); median MBL was 33.1 ml. Menorrhagia was more frequent in girls who had menstruated for > 2 years (P = 0.048), and had longer duration of menses (P < 0.001). Iron status as measured by haematocrit, serum iron, transferrin saturation and ZPP values was inversely related to MBL. Neither height nor body mass index for age was associated with current iron status.nnnCONCLUSIONSnThe level of menorrhagia detected (12%) may be an expected level for a condition which often has no underlying pathology. Heavy MBL is one of the most important factors contributing to iron deficiency anaemia. Measures are needed to alleviate menstrual disorders, and improve iron status. Oral contraceptives can be part of a strategy to reduce anaemia, particularly for adolescents at high risk of unwanted pregnancies.

The epidemiological significance of Chagas' disease in womem

Little is known about the risks associated with Trypanosoma cruzi infection in non-pregnant and pregnant women. From a limited number of studies it appears that in rural areas, parasite rates and rates of serological positivity are similar in both sexes. Abnormal ECG tracings are consistently more frequent in men suggesting that immunity to T. cruzi may be different in females. Complications arising from Chagas disease in pregnancy are only infrequently reported. Evidence for increased risk of abortion or prematurity is inconclusive except in cases of congenital infection. Most cases of congenital Chagas disease have been reported from non-endemic areas and there is a suggestion that parasitemic episodes during pregnancy may influence pregnancy outcome. Preliminary evidence indicates that chronic infection can result in in-utero sensitization via passively acquired maternal antibodies. The review concludes that maternal T. cruzi infection carries risks for the child and these warrant systematic research because of their public health significance.

Providing accessible health care for adolescents with sexually transmitted disease

Provision of sexually transmitted disease (STD) care for sexually active adolescents has been neglected in developing countries, although this is changing. Available evidence indicates that STDs are a serious problem among adolescents (10-19 years), especially in rural areas where services are limited for any age group. Curative care is hampered by the inadequacy of the syndromic approach for identifying adolescents with asymptomatic infections, especially Chlamydia trachomatis. There is an urgent need to asses STD interventions for adolescents in controlled studies, with numbers and follow-up sufficient to monitor changes in STD markers. Many programmes report increased uptake of condoms by youth but have been unable to demonstrate its effect on STD/HIV rates. It is unlikely that any one approach to adolescent STD services will be feasible and hence the importance of understanding the benefits and limitations of each approach.

Effectiveness of drama in promoting voluntary HIV counselling and testing in rural villages in southern Malawi.

We previously reported an HIV prevalence of 24% among rural adolescent girls living in the Shire Valley southern Malawi. Voluntary HIV counselling and testing (VCT) could help prevent HIV among adolescents by encouraging informed decision-making and behavioural change. The Malawian National AIDS Control Programme has prioritized VCT as an HIV prevention strategy but it is unclear whether adolescents in rural areas are informed about VCT and how acceptable HIV testing would be to adolescents and parents. We undertook a study to assess the role of drama as a tool to promote knowledge of and positive attitudes towards VCT. The study was undertaken in 2003 in seven villages in Chikwawa District within a 12 km radius of Montfort Hospital. VCT services were available at Montfort although only 7% of clients in the previous year were adolescents. Two counsellors were interviewed about issues faced by adolescents going for VCT and these formed the basis for the drama script. The drama which was translated into Chichewa comprised songs giving information on HIV/VCT a 30-minute drama and an epilogue and was performed by two drama groups (hospital and youth). In each village on the day of the drama 25 adolescents (15–19 years) and 25 adults who had an adolescent child were asked to complete a questionnaire before and after the performance. In two villages the questionnaire was re-administered four weeks later to assess knowledge retention. The study was approved by Ethics Committees in Liverpool and Malawi. (excerpt)

Difficulties of interpreting PPD reactions of women living in Madang, Papua New Guinea

Malaria surveys in Madang, Papua New Guinea, previously distinguished 2 populations of women with significantly different spleen rates and immune responses to malaria. Differences between the high (HS) and low (LS) spleen rate groups suggested a defect in cellular immunity in the HS group. This paper reports a survey of purified protein derivative (PPD) responses in a sample of HS and LS women. Eighty-eight of 162 women were PPD positive (reaction size > 5 mm). There was a marked difference in the range and size of PPD reaction between the HS and LS groups. Mean size in the LS group was 20.7 mm and in the HS group it was 12.1 mm (P = 0.02). Failure to show differences in other indicators of specific malaria immunity indicated that the difference in PPD response was not the result of malaria-specific cell-mediated immune suppression. Many women were PPD non-responders in spite of evidence of multiple bacillus Calmette-Guérin (BCG) vaccination scars. There was no difference between HS and LS groups in the level of non-response to PPD. The results confirm an early tuberculosis survey indicating that New Guineans rapidly lose PPD reactivity to BCG vaccination. Ability to maintain a PPD response, and the quality of response, may vary according to sex and genetic background.