The Health District of Bonassama in the littoral region of Cameroon published its results for the selection of a civil society organizations(CSO) and community based organizations (CBO) to scale up malaria for impact on the 30th May 2011. Cameroon Link tops the list of six civil society organizations with a 100% score, followed by COGESID Baobab with 69% and Organisation Nationale de Droit de l’Homme (ONDH) scoring 50%. Three of organization GIC Maranatha, Jeunes Dynamiques (JEDY) and Association des Jeunes pour le Développement de Ilongue/Malimba(AJDIM) were disqualified from the race as not belonging or operating in the health district of Bonassama.
The selection was endorsed by the head of Bonassama Health District, Dr. Nzima Nzima Valery, 2nd Deputy Mayor of Douala IV, Manbagap Paul and the chair of the health district committee, Diboa Samuel. As concerns the community based organizations, 110 candidates went in for the selection test and only 99 quqlified. According to Dr. Nzima Nzima, the territory covered by the health district of Bonassama is using 110 CBOs, meaning 11 community based organizations need to be deployed for a full outreach of the population of the district.
Bonassama Health District is comprised of 11 health ares: Bonassama, Bonamikano, Nkomba, Mambanda, Bilingue, Ngwele, Bonendale, Bojongo, Djebale, Sodiko and Grand Hangar. The President of Cameroon Link; James Achanyi-Fontem, has explored issues that motivate the participation of his organization in the Global Fund Programme piloted by Plan Cameroon. Read about the burden of Malaria in pregnancy in Malaria-Endemic areas below:
The Burden of Malaria in Pregnancy in Malaria-Endemic Areas
By James Achanyi-Fontem,
CEO, Cameroon Link
Email: camlink99@gmail.com
Pregnant women in malarious areas may experience a variety of adverse consequences from malaria infection including maternal anemia, placental accumulation of parasites, low birth weight (LBW) from prematurity and intrauterine growth retardation (IUGR), fetal parasite exposure and congenital infection, and infant mortality (IM) linked to preterm-LBW and IUGR-LBW. Between 1985 and 2000, studies were and the malaria population attributable risk (PAR) that accounts for both the prevalence of the risk factors in the population and the magnitude of the associated risk for anemia, LBW, and IM was summarized. Consequences from anemia and human immunodeficiency virus infection in these studies were also considered. Population attributable risks were substantial: malaria was associated with anemia (PAR range = 3–15%), LBW (8–14%), preterm-LBW (8–36%), IUGR-LBW (13–70%), and IM (3–8%). Human immunodeficiency virus was associated with anemia (PAR range = 12–14%), LBW (11–38%), and direct transmission in 20–40% of newborns, with direct mortality consequences. Maternal anemia was associated with LBW (PAR range = 7–18%), and fetal anemia was associated with increased IM (PAR not available). It is estimated that each year 75,000 to 200,000 infant deaths are associated with malaria infection in pregnancy. The failure to apply known effective antimalarial interventions through antenatal programs continues to contribute substantially to infant deaths globally.
The problem of malaria infection in pregnant women was initially described nearly 65 years ago.1 Descriptive studies in sub-Saharan Africa from the 1950s through 1984 focused on Plasmodium falciparum infections and described the frequency of placental infection and specific adverse consequences.2–7 Relatively few population-based studies have been reported from Asia or the Americas, and where studies do exist, most have focused on high-transmission areas and infections with P. falciparum.8 Infection rates have been consistently demonstrated to be highest in women in their first and second pregnancies, with lower rates in later pregnancies.8–20 Because of high rates of parasitemia in pregnancy, particularly in many settings in sub-Saharan Africa, the World Health Organization has recommended presumptive malarial treatment followed by additional prevention measures during pregnancy.11
Plasmodium falciparum infection in pregnancy leads to parasite sequestration in the maternal placental vascular space, with consequent maternal anemia7, 12, 13 and infant low birth weight (LBW)8–10, 14–17 due to both prematurity15, 17 and intrauterine growth retardation (IUGR);8, 14, 15, 17 LBW is known to be the most important risk factor for infant mortality.18, 19 Anemia, undernutrition, and human immunodeficiency virus (HIV) infection are also common events in malarious areas and contribute to LBW. Malaria infection in pregnancy may lead to anemia in pregnancy, and HIV infection in pregnancy confers additional risk for higher frequency and higher density of malaria during pregnancy;20 thus, these conditions are integrally linked, and P. falciparum is not the only cause of LBW in these malaria-endemic settings.18 Low birth weight is also associated with newborn gender (more common in girls), maternal stature (more common in shorter and smaller women), and birth order (more common in first or low-birth-order pregnancies); however, these characteristics cannot be changed and are not amenable to interventions once a pregnancy has begun.
In the next year, an estimated more than 50 million pregnancies will occur in malaria-endemic areas, and approximately half of these will be in sub-Saharan Africa, where P. falciparum transmission is most intense.21 To assess the magnitude of the burden of malaria in pregnancy and its contribution to infant mortality, data from published and unpublished studies during the last 15 yr (1985–2000) and focused on sub-Saharan Africa was evaluated. This was where data are most available, because of the multiple pathways for the chain of events between maternal malaria infection and infant mortality. Experts specifically sought studies that evaluated malaria, anemia, and HIV infection and their contribution to low birth weight and potentially to infant mortality. There is a paucity of population-based data on malaria in pregnancy in settings of low malaria endemicity. Because malaria exposure in pregnancy is much less common in these lower-endemicity settings and may be caused by nonfalciparum species, which are thought to have less impact on the pregnancy, the burden of malaria in pregnancy in these other settings is likely to be relatively lower. However, because of our focus on the higher-endemicity settings, the estimates obtained from our review likely underestimate the total global burden of malaria infection in pregnancy.
Methods
Studies were reviewed and reported between 1985 and 2000 in which information was available on malaria infection in pregnancy; associated conditions (e.g., anemia, HIV infection); and/or adverse outcomes of pregnancy, including low birth weight, prematurity, and infant mortality. Medical specialists conducted a literature search using MEDLINE, cross-referencing the following terms: 1) malaria or falciparum malaria, 2) pregnancy, pregnancy complications, or pregnancy complications infectious, 3) HIV or HIV-1, and 4) anemia. For the designated years of 1985–2000, this review yielded 789 articles for categories 1+2 (malaria and pregnancy), 55 articles for categories 1+2+3, 98 articles for categories 1+2+4, and 15 articles for categories 1+2+3+4. Only articles written in English were reviewed. Because the search did not identify certain articles that were known to the researchers, who used references from selected articles to identify additional published literature for review. They also reviewed unpublished data from large studies for which published information was not yet available in countries like Mali and Kenya.
To be considered for incorporation in the final review, articles had to provide information on the frequency or prevalence of outcomes and risk factors and information on risk estimates, preferably from multivariate analysis for associations between multiple purported risk factors and outcomes. They focused on outcomes of maternal malaria infection (peripheral or placental infection), maternal anemia, LBW, preterm-LBW, IUGR-LBW, and infant mortality. When possible, they examined the contributions of P. falciparum malaria, anemia, and HIV to these adverse outcomes, both because each condition likely affects the others and because the evaluation allowed for relative comparisons of their impact on infant mortality, either directly (with HIV infection in the newborn) or through the contribution to preterm-LBW or IUGR-LBW. Maternal malaria infection and anemia were considered as risk factors and as outcomes in these analyses, because HIV may contribute to increased risk for malaria and malaria may contribute to increased risk of anemia. Only 2 study settings reported on estimates of the full sequence of events (e.g., malaria → BW → infant mortality) however, because the infant mortality risk associated with LBW is described in a variety of populations around the world, it was assumed that contributors to LBW were linked to subsequent infant mortality.
Finally, the researchers evaluated studies of interventions and the estimates of efficacy for interventions, examining the impact of ‘‘failing to use existing effective interventions’’ as a risk factor for the burden of malaria, LBW, and infant mortality. Because malaria prevention in pregnancy is not widely implemented and because few studies report on the actual implementation of interventions, it was assumed that the prevalence of the risk factor (i.e., ‘‘not receiving the intervention’’) was 90% in the populations.
Results
A total of 34 reports were considered for this review .These reports came from 25 investigations in 8 sub-Saharan African countries (Kenya = 6 investigations; Malawi = 5; Tanzania = 3; Gambia = 2; Burkina Faso = 1; Cameroon = 1; Mali = 1; Mozambique = 1; and Uganda = 1) and 2 non-African settings (Papua New Guinea = 2 investigations; Thailand = 2). The study group sizes ranged from 159 to greater than 10,000 persons, and endemicity varied as seen by variations in maternal parasitemia rates between 6% in urban Mozambique and 65% in Tanzania. Additionally, the categorization of variables ranged widely, as demonstrated by the variable criteria for anemia (any, mild or moderate, or severe). Finally, 12 studies were largely observational but may have reported on the effect of interventions, whereas 13 studies involved intervention trials.
Malaria
Plasmodium falciparum malaria in pregnancy appeared to contribute to anemia and LBW through both preterm-LBW and IUGR-LBW in a relatively consistent fashion across different studies and settings. The prevalence of malaria infection in pregnancy ranged from approximately 10% to 65% across the settings where these associations were observed. The prevalence of the conditions of severe anemia, LBW, preterm-LBW, and IUGR-LBW; the risk estimates from various studies; and the PAR for malaria’s contribution to these conditions are high. Estimates of malaria’s contribution to LBW were modest and consistent across studies—accounting for approximately 8–14% of LBW and IUGR-LBW and approximately 8–36% of preterm LBW.
From 2 studies, maternal malaria was estimated to contribute to 3–8% of infant mortality. One study47 provided a much higher PAR estimate (30%) for infant mortality caused by maternal malaria infection, but this was an ecologic comparison between very different communities, and unmeasured contributions to infant mortality may have biased this estimate.
Anemia
Maternal anemia during pregnancy, associated with maternal malaria or many other causes, ranged in prevalence from 2–30% (based on differing cutoffs for hemoglobin levels; Maternal anemia appears to contribute to a PAR ranging from 7% to 18% for LBW and less than 48% for IUGR-LBW. Published studies did not describe relative contributions to preterm-LBW, and one indirect estimate suggested that maternal anemia may contribute to approximately one-fourth of infant mortality. Summary associations and population attributable risk (PAR) estimates for anemia in pregnant women and its contribution to low birth weight (LBW) attributable to preterm delivery or intrauterine
HIV
Maternal HIV infection has been shown to contribute to maternal malaria, maternal anemia, LBW, and direct infection of the newborn infant, which currently is 100% fatal. The prevalence of maternal HIV infection in areas where maternal malaria studies have been reported has ranged from 3% to 27%. HIV is estimated to contribute to malaria infection in pregnancy (PAR = 10–27%), maternal anemia (PAR = 12–15%), and LBW (PAR = 11–38%). Because HIV infection of the newborn is fatal, the contribution of HIV to infant mortality may reach or exceed 50% in some settings with high rates of maternal HIV infection and high rates of mother-to-infant HIV transmission.
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