|Year : 2019 | Volume
| Issue : 2 | Page : 96-101
Incidence and Predictors of Neonatal Malaria among Newborns admitted within the first 28 days of Life to a Tertiary Healthcare Facility in South-East Nigeria
Linda Nwokeji-Onwe1, Abraham B Onwe2, Kenechukwu K Iloh2, Uzoamaka Muoneke2, Nnaemeka K Omeje1, Ogochukwu Iloh2, Chidiebere D I Osuorah3
1 Department of Paediatrics, Federal Teaching Hospital, Abakaliki, Nigeria
2 Department of Paediatric, University of Nigeria Teaching Hospital, Nsukka, Nigeria
3 Child Survival Unit, Medical Research Council UK, Gambia Unit, Fajara, The Gambia
|Date of Web Publication||25-Apr-2019|
Dr. Chidiebere D I Osuorah
Child Survival Unit, Medical Research Council UK, Gambia Unit, Fajara
Source of Support: None, Conflict of Interest: None
Background: The burden of malaria in newborn babies has been a subject of concern as there are variations in published reports. However, incidence and prevalence of malaria parasitemia among newborn babies aged zero to 28 days has not been well reported in Nigeria. Objective: This work sought to determine the incidence of malaria parasitemia in newborn babies aged 0–28 days and determinants of malaria parasitemia in these newborns. Methodology: This descriptive study was conducted over a 7-month period. Four hundred and thirty neonates admitted in the Federal Teaching Hospital Abakaliki that met the inclusion criteria were consecutively enrolled after obtaining consent from their parent(s)/caregiver. Data on sociodemographics of the mother and neonates were obtained using interviewer-administered questionnaire. Blood samples were collected from neonates for malaria parasitemia using blood film microscopy. Results: Of the 430 newborns admitted during the study period, 19 (4.4%) had neonatal malaria with 94.7% (18/19) of those diagnosed between birth and the 7th day of life. This resulted to an in-hospital incidence rate of 44.19 (95% confidence interval 24.33–64.05) per 1000 admitted newborns. Only the use of insecticide-treated bed net during pregnancy was significantly associated with reduction of malaria transmission from the mother to their babies. Conclusions: Malaria in neonates is a prevalent but commonly overlooked cause of morbidity in newborn in the first 28 days of life. Adequate measures to prevent malaria infection in pregnant mothers could help in reducing morbidity and mortality associated with malaria in neonates.
Keywords: Abakaliki, malaria, neonates, parasite
|How to cite this article:|
Nwokeji-Onwe L, Onwe AB, Iloh KK, Muoneke U, Omeje NK, Iloh O, Osuorah CD. Incidence and Predictors of Neonatal Malaria among Newborns admitted within the first 28 days of Life to a Tertiary Healthcare Facility in South-East Nigeria. J Clin Neonatol 2019;8:96-101
|How to cite this URL:|
Nwokeji-Onwe L, Onwe AB, Iloh KK, Muoneke U, Omeje NK, Iloh O, Osuorah CD. Incidence and Predictors of Neonatal Malaria among Newborns admitted within the first 28 days of Life to a Tertiary Healthcare Facility in South-East Nigeria. J Clin Neonatol [serial online] 2019 [cited 2019 Nov 18];8:96-101. Available from: http://www.jcnonweb.com/text.asp?2019/8/2/96/257132
| Introduction|| |
Globally, there are about 3.4 billion of the world population at risk of malaria with 1.2 billion at high risk of the disease. In the year 2010, the World Health Organization (WHO) stated that 219 million cases of malaria occurred globally. Of the 219 million cases of malaria, 40% occurred in Nigeria of which 660,000 deaths were recorded. About 90% of all malaria deaths occurred in sub-Saharan Africa. In the year 2012, malaria killed an estimated 482,000 children under 5 years of age, implying that a child dies every minute or 1300 children each day from malaria in sub-Saharan Africa. Malaria accounts for about 60% of outpatient visits to health facilities, 30% of hospitalizations among children under 5 years of age, and 25% of deaths in children under 1 year., Children under 5 years have as many as three to four episodes of malaria every year. Malaria can occur at birth through to the 1st week as congenital malaria or after the 1st week as neonatal malaria. However, its true burden in the neonatal period is underreported as most literatures lump the burden of malaria occurring in the under-fives together., Empirical observation in the newborn special care unit of the Federal Teaching Hospital, Abakaliki (FETHA) has shown that appreciable number of neonates who were being treated for sepsis turned out to have neonatal malaria and responded well to antimalarial therapy. The reported prevalence rates of malaria among children aged 6–59 months range from 27.6% to 50.3%,, but there is a dearth of information concerning the prevalence of malaria parasitemia in the neonates, especially in South East Nigeria. There is a need to establish the prevalence and pattern of malaria among neonates. Not only will this fill the existing gap in knowledge in this locality, but will also raise awareness and bring about prompt attention to malaria in the newborn. Furthermore, testing for malaria parasitemia in the neonates will aid in the rationale use of antibiotics and limit resistance. This will invariably significantly reduce the mortality associated with the disease in these vulnerable neonates. The aim of this study was therefore to evaluate the incidence and predictors of malaria among neonates admitted to the FETHA. This we believe will help raise awareness of the possibility of malaria in newborn babies and inform prompt diagnosis and treatment.
| Methodology|| |
Abakaliki is the capital and largest city of Ebonyi State located in south-east Nigeria. Abakaliki is inhabited primarily by the Igbo ethnic group. The capital city has a population of about 151,723 according to the 2006 population census with a land area of about 5935 km2. Its inhabitants are of different educational attainment. About 75% of the population of Ebonyi state are rural dwellers with subsistence farming as the main occupation. The socio-economic indices is characterized by low literacy levels, and high poverty rates. Ebonyi is bounded to the North by Benue State, to the West by the Enugu State, to the East by the Cross-River State, and to the South by Abia State. It lies approximately within longitudes 70°30'and 80°30'E and latitudes 50°40' and 60°45'N. There are many primary and secondary health facilities in the state with the FETHA being the only tertiary hospital and a major referral health facility providing both general and specialist care to inhabitants of the state and its environs.
The newborn special care unit of FETHA caters for babies from the 1st day of life to the 28th day of life. It has two sections, one for inborn and the other for babies referred from outside the hospital. An average of 50 babies are admitted in both wards per month with a total of 591 admitted during the study year. Services are rendered all through the day. The labor ward of FETHA has a delivery room with six couches and a fourth stage room with twelve beds. Mothers and their babies are kept in the fourth stage room immediately after delivery until 2 hours post delivery before transfer to the postnatal ward. The total number of babies delivered during the study period was 2416 giving an average of 200 deliveries per month.
Participants were newborn babies from birth to 28 days of life. Inclusion criteria inluded term and preterm newborns delivered and/or admitted into the newborn special care unit of the FETHA, irrespective of indication for admission. Newborn babies whose parents refused consent, those already on treatment for malaria, or have been treated for malaria, and babies who have received blood transfusion before admission were excluded from the study.
This was a descriptive study. Newborn delivered in FETHA or referred to it that satisfied the inclusion criteria were consecutively enrolled over a 7-month period. Informed consent was obtained from the parents and/or caregivers. The number of newborns enrolled was calculated based on an assumed neonatal malaria prevalence rate of 50%, a 5% precision degree and a 10% default rate to accommodate for possible sample loss due to attrition.
Ethical approval and consent
Ethical approval was obtained from the Ethics and Research Committee of the FETHA with reference number FETHA/REC/VOL1/2015241. Approval from the parents/caregiver was obtained through the consent letter. For those unable to read, the form was explained verbally by a research assistant in a language that they could understand. Confidentiality was maintained. Patient identity was coded, and all relevant information concerning the study was kept in sole custody of the principal researchers.
Data collection was done by trained research assistants who are registrars in the department of pediatric. The assistants were trained on administration of the study tool. Parent(s) or caregiver(s) of babies who met the inclusion criteria were approached by the research assistants after the delivery or admission of the neonates. A pro-forma was used to obtain information on demographic variables such as maternal age, marital status, parent's occupation, and parent's highest educational qualification. Obstetric history on the number of deliveries, fever in pregnancy, and maternal knowledge of intermittent preventive therapy (IPT) for malaria was also obtained. Other information obtained included baby's age in days, sex, birth weight, and symptoms the baby presented with, if any.
The principal investigator performed the sample collection after introducing self to the parent(s) or caregiver(s) of each newborn. Materials such as gloves, methylated spirit, cotton wool, lancet (ACCU-CHEK, 28G, 0.4 mm), and micropipette were assembled on a tray. Thick and thin smear template was used. The researchers observed universal precautions. Each slide was cleaned with dry cotton wool to wipe off dirt from the surface and labeled with a marker bearing the child's initials, a unique serial number with the date of the sample collection. Blood sample was collected from the lateral aspect of the middle finger or the heel after thorough cleaning with a methylated spirit swab. The calibrated micropipette was used to obtain blood from the punctured site, and a drop of blood measuring 12 μl was placed at the center of the slides.
In making the thick film, blood was dropped at the center of the slide guided by the template and another clean spreader slide was used to make the smear in four circles to avoid breaking the cytoplasm of the malaria parasite due to fragility of the parasites. To make the thin film, the micropipette was adjusted to drop 4 μl of blood at the other side of the slide. A spreader slide held at angle of 45° toward the blood was used to push the blood smoothly and rapidly. Thereafter, the slides were allowed to air dry completely. Within 1 h, the dried slides were transported in slide box to the laboratory. The microscopist stained and read the slides with the researchers present during the whole process. The thin film was fixed with 100% methanol and allowed to dry. Three percent stock solution of Giemsa stain was used in staining both the thick and thin film. After staining, the slides were washed with buffered distilled water and allowed to air dry. This was followed by reading the slides under the microscope at ×100 oil immersion magnification. A thick film was said to be malaria parasite negative or positive after examination of a 100 high power fields. Parasite density was recorded as a ratio of parasites to white blood cells (WBCs) in thick films. WBCs were indirectly and relatively used in microscopy to estimate the density of malaria parasite infections using the following formula:
According to the WHO standard, 8000 is a constant based on assumption that there is an average of 8000 WBC per microliter. Two microscopists were involved in the microscopy. A WHO-trained and certified microscopist reviewed all the slides for quality assurance. Quality assurance was ensured in the preparation of the smear, ensuring that the buffered distilled water had a pH of 7.2 as most available water in the environment are acidic. Furthermore, the slide was properly air-dried to avoid the smear being washed off. The slide was flooded with appropriate volume of Giemsa stain. The time of staining was kept for 10 min. The microscopists read the slides independent of each other, and the findings were subsequently compared. Any conflicting slide was isolated for a recheck.
Data obtained were collated and analyzed with Epi info version 126.96.36.199 (CDC Georgia USA 2011). The level of significance was set at P < 0.05. The cross tabulations of malaria parasitemia with independent variables in 2 × 2 tables were compared using the Pearson Chi-square test. The results were presented in charts and tables.
| Results|| |
Characteristics of newborns and mothers and/or caregivers surveyed
The 430 neonates enrolled comprised of 214 (49.8%) males and 216 (50.2%) females. Four hundred and three, 403 (94%) of the enrolled newborns were delivered within the study facility with 358 of these recruited directly from the postnatal ward and 45 from the newborn unit. The remaining 27 newborns were referrals from peripheral hospitals (outborns). The mean age of the neonates is 4.4 (±5.4) days. The sociodemographic characteristics of the neonates recruited are shown in [Table 1]. The mothers that participated in the study had a mean age of 27.8 (±4.8) years with a range of 14–40 years. Two hundred and forty (55.8%) had fever in pregnancy. About 47% of these had one episode while 31.6% and 19.9% had 2 and ≥3 episodes of fever, respectively. Among the mothers that had fever in pregnancy, 51.2% received antimalarial medications. Three hundred and sixty-four mothers, 364 (84.7%) knew about IPT for malaria of whom 79.8% (343) received it. [Table 1] also shows the characteristics of mothers of newborns enrolled. A majority of them were married and had secondary school education. The highest proportion of mothers were from the low socioeconomic class.
|Table 1: Characteristics of newborns and mothers/ caregivers enrolled in the study|
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Incidence of malaria parasitemia in surveyed newborns
Out of the 430 neonates enrolled, 19 (4.4%) had a positive malaria test on blood film microscopy which gave an in-hospital incidence rate of 44.19 (95% confidence interval [CI] 24.33–64.05) per 1000 admitted newborns. Seventeen of the 19 neonates with malaria parasitemia were delivered in FETHA. The mean age of the newborns at diagnosis of neonatal malaria parasitemia was 1.05 (±0.23) days, and the mean malaria parasite density was 142.7 ± 70.9 p/μl. The predominant stage seen was the trophozoite, and Plasmodium falciparum was the only species identified on thin film examinations of blood samples. All but one of the newborn babies had malaria parasitemia within the 1st week of life. The female to male ratio of neonates with malaria was 1.4:1.
[Table 2] shows the presence of malaria parasitemia stratified by maternal and newborn sociodemographic characteristics of interest. More newborns ≤7 days (P = 0.23), term at birth (P = 0.81), and female (P = 0.65) had malaria parasitemia compared to newborns in the corresponding categories. None of these parameters were however significantly associated with malaria parasitemia in surveyed newborns. Similarly, maternal fever in pregnancy (P = 0.11), mother's parity (P = 0.56), use of IPT (P = 0.93), or antimalaria medication (P = 0.13) in index pregnancy were not significantly associated with parasitemia in newborn. Only the use insecticide-treated net (ITN) in pregnancy was significantly associated with malaria infection in newborns of respondents. Mothers that used insecticide-treated bed nets had lower prevalence rate of malaria in their newborns – 6 (2%) compared to those that did not use nets – 3 (8%); P = 0.001. In other words, the relative risk (RR) of acquiring malaria by neonates whose mother slept under insecticide-treated bed nets was 0.299 less compared to neonates whose mother did not use ITN (RR 0.299 [95% CI 0.116–0.771, P = 0.013]).
|Table 2: Malaria parasitemia stratified by maternal and newborn parameters|
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| Discussion|| |
The prevalence of malaria in neonates has been a subject of concern as there are wide variations in published reports. In this study, the observed prevalence of malaria parasitemia was 4.4%. This was comparable to 5.1% by Falade et al. in the multicentered study in Nigeria and 5.81% in Enugu by Okafor et al. Similar studies reported in Sagamu (24.8%) and Ile-Ife (46.7%) in South West Nigeria demonstrated higher prevalence. The low prevalence of neonatal malaria reported in this study may be related to the high proportion of mothers that used IPT for malaria (≈80%) and slept under an insecticide-treated bed net in the index pregnancy (≈61%). Geographical locations and difference in climate conditions of the sites at the time of the studies may also contribute to these differences.
The P. falciparum was the only species found in this study. Similar findings of P. falciparum as the only species found in neonates with malaria parasitemia have been reported severally in the literature.,, This agrees with the well-documented finding of P. falciparum being the most dominant malaria species in Nigeria. The predominant developmental stage of malaria parasite seen in this study was the trophozoites. Trophozoites known as the “ring form” are seen inside the red blood cell. This could be coincidental being the point when the blood samples were collected.
Our study showed that the prevalence of malaria parasitemia was higher in neonates of primiparous mothers though statistical significance was not attained. Nnaji et al. in Anambra and Nwangwa and Ekhoye in Benin reported that malaria parasitemia was significantly higher in neonates of primiparous mothers. This supports the findings in this study. McGregor et al. reported that in the primiparous mother, placental is immunologically malaria-naïve and it requires a long period of exposure before the maternal immune system can recognize the placenta-sheltered parasites and respond appropriately. Adebami et al. attributed the higher malaria parasitemia seen in neonates of primiparous mothers to be due to immunity-related factors such as nonspecific immunosuppression from the increased production of steroids. This finding differs from the finding of Odikamnoro et al. in Abakaliki, Nigeria who reported higher malaria infection in neonates of multigravida mothers suggesting that the protecting immunity in pregnancy is not a function of parity. Furthermore, Shulman et al. reported that the immunity built up is achieved after several pregnancies and infections.
Our study showed no relationship between malaria parasitemia and the birth weight or gestational age of surveyed newborns. This agrees with the findings by Mosha et al. However, it differs from the findings of Akum et al., Mwangoka et al., and Nwali et al. These studies reported low birth weight to be associated with higher malaria parasitemia. Nwali et al. in Abakaliki attributed it to the infection of the placenta by malaria which might have induced changes in the placental structure and function leading to low birth weight. Similarly, though our study showed that majority of the neonates with malaria parasitemia were of mothers in the low socioeconomic class, no significant association was reported. Adebami et al. in their study saw a higher malaria parasitemia in neonates from the low socioeconomic status and attributed this to the poor health-seeking behavior, poverty, poor nutrition, and poor environmental sanitation which could lead to the promotion of malaria infestation/infection.
Finally, it was noted in this study that the use of insecticide-treated bed net by mothers was significantly associated with lower prevalence of malaria in neonates. This finding collaborates the recommendation of the Centers for Disease Control and Prevention on the use of insecticide-treated bed net in malaria-endemic areas as it has been demonstrated that it's use reduces the burden of malaria disease in the neonates and pregnant women.
One of the biggest limitations of our study is the lack of documented evidence of malaria in mothers during pregnancy. This, together with the possibility of recall bias on vital information during pregnancy may have affected the quality of data collected for this study leading to errors in classification and research findings.
| Conclusions|| |
Despite the limitations, the following conclusions can be drawn from the results of this study. First, the in-hospital incidence rate of malaria among neonates within the first 28 days of life is high, 44.19 (95% CI 24.33–64.05) per 1000 admitted newborns. Second, no age and gender predilection for malaria parasitemia was found among neonates surveyed in this study. Furthermore, the use of ITN for prevention of malaria is effective in reducing the rate of transmission from mother to their offspring, and finally, the use of IPT did not influence the occurrence of malaria parasitemia in the neonates.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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