Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya.
Malar J. 2020 Nov 25;19(1):433. doi: 10.1186/s12936-020-03505-0.
Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for preventing malaria in pregnancy in areas of moderate-to-high transmission in sub-Saharan Africa. However, due to increasing parasite resistance to SP, research on alternative strategies is a priority. The study assessed the implementation feasibility of intermittent screening and treatment (ISTp) in the second and third trimester at antenatal care (ANC) with malaria rapid diagnostic tests (RDTs) and treatment of positive cases with dihydroartemisinin-piperaquine (DP) compared to IPTp-SP in western Kenya.
A 10-month implementation study was conducted in 12 government health facilities in four sub-counties. Six health facilities were assigned to either ISTp-DP or IPTp-SP. Evaluation comprised of facility audits, ANC observations, and exit interviews. Intermediate and cumulative effectiveness analyses were performed on all processes involved in delivery of ISTp-DP including RDT proficiency and IPTp-SP ± directly observed therapy (DOT, standard of care). Logistic regression was used to identify predictors of receiving each intervention.
A total of 388 and 389 women were recruited in the ISTp-DP and IPTp-SP arms, respectively. For ISTp-DP, 90% (289/320) of eligible women received an RDT. Of 11% (32/289) who tested positive, 71% received the correct dose of DP and 31% the first dose by DOT, and only 6% were counselled on subsequent doses. Women making a sick visit and being tested in a facility with a resident microscopist were more likely to receive ISTp-DP (AOR 1.78, 95% CI 1.31, 2.41; and AOR 3.75, 95% CI 1.31, 2.40, respectively). For IPTp-SP, only 57% received a dose of SP by DOT. Payment for a laboratory test was independently associated with receipt of SP by DOT (AOR 6.43, 95% CI 2.07, 19.98).
The findings indicate that the systems effectiveness of ANC clinics to deliver ISTp-DP under routine conditions was poor in comparison to IPTp-SP. Several challenges to integration of ISTp with ANC were identified that may need to be considered by countries that have introduced screening at first ANC visit and, potentially, for future adoption of ISTp with more sensitive RDTs. Understanding the effectiveness of ISTp-DP will require additional research on pregnant women's adherence to ACT.
在中高度疟疾传播地区，推荐采用磺胺多辛-乙胺嘧啶（SP）间歇性预防治疗（IPTp）来预防妊娠疟疾。然而，由于寄生虫对 SP 的抗药性不断增强，因此研究替代策略是当务之急。本研究在肯尼亚西部评估了在产前保健（ANC）中采用基于疟疾快速诊断检测（RDT）的间歇性筛查和治疗（ISTp）方案，在妊娠第二和第三孕期时，每两个月用二氢青蒿素-哌喹（DP）治疗阳性病例，与 IPTp-SP 相比，其实施的可行性。
在肯尼亚西部四个县的 12 家政府卫生机构进行了为期 10 个月的实施研究。6 家卫生机构被分配到 ISTp-DP 或 IPTp-SP 组。评估包括机构审计、ANC 观察和出院面谈。对 ISTp-DP 方案实施过程中的所有流程（包括 RDT 熟练程度和 IPTp-SP±直接观察治疗（DOT，标准护理））进行了中期和累积有效性分析。采用逻辑回归确定了接受每种干预措施的预测因素。
ISTp-DP 组和 IPTp-SP 组分别招募了 388 名和 389 名妇女。对于 ISTp-DP，90%（289/320）符合条件的妇女接受了 RDT 检测。在 11%（32/289）检测呈阳性的妇女中，71%接受了正确剂量的 DP，31%接受了 DOT 首剂治疗，只有 6%接受了后续剂量的咨询。因病就诊和在有常驻显微镜检查员的机构接受检测的妇女更有可能接受 ISTp-DP（优势比 1.78，95%置信区间 1.31-2.41；和优势比 3.75，95%置信区间 1.31-2.40）。对于 IPTp-SP，只有 57%的妇女接受了 DOT 治疗的 SP 剂量。实验室检测费用是接受 DOT 治疗 SP 的独立影响因素（优势比 6.43，95%置信区间 2.07-19.98）。
研究结果表明，与 IPTp-SP 相比， ANC 诊所提供 ISTp-DP 的系统效果较差。在将 ISTp 与 ANC 结合方面发现了一些挑战，可能需要在已引入首次 ANC 就诊筛查的国家，以及可能在未来采用更敏感的 RDT 时，考虑这些挑战。要了解 ISTp-DP 的有效性，还需要对孕妇对 ACT 的依从性进行进一步研究。
