Hindawi Publishing Corporation

BioMed Research International

Volume 2015, Article ID 740512, 16 pages
http://dx.doi.org/10.1155/2015/740512

Research Article
Prevalence of Malaria Infection and Risk Factors Associated with
Anaemia among Pregnant Women in Semiurban Community of
Hazaribag, Jharkhand, India

Mohammad Sohail,1 Shayan Shakeel,1 Shweta Kumari,1 Aakanksha Bharti,2 Faisal Zahid,3
Shadab Anwar,4 Krishn Pratap Singh,4 Mazahirul Islam,5 Ajay Kumar Sharma,1
Sneh Lata,6 Vahab Ali,4 Tridibes Adak,7 Pradeep Das,8 and Mohammad Raziuddin1,9
1
University Department of Zoology, Faculty of Sciences, Vinoba Bhave University, Hazaribag, Jharkhand 825301, India
2
Department of Biotechnology, VIT University, Vellore, India
3
Department of Biotechnology, Shri Venkateshwara University, Amroha, India
4
Division of Biochemistry, Rajendra Memorial Research Institute of Medical Sciences (ICMR), Agam Kuan, Patna 800007, India
5
Medical Biology Department, Deanship of Preparatory Year, Jazan University, Jizan, Saudi Arabia
6
Female OPD, Sadar Hospital, Hazaribag, Jharkhand 825301, India
7
National Institute of Malaria Research (ICMR), Sector 8, Dawarka, Delhi 110077, India
8
Division of Molecular Biology, Rajendra Memorial Research Institute of Medical Sciences (ICMR), Agam Kuan, Patna 800007, India
9
Ranchi University, Ranchi, Jharkhand 834001, India

Correspondence should be addressed to Mohammad Sohail; [email protected]

and Mohammad Raziuddin; [email protected]

Received 10 June 2015; Accepted 13 August 2015

Academic Editor: Lidia Chomicz

Copyright © 2015 Mohammad Sohail et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

The escalating burden, pathogenesis, and clinical sequel of malaria during pregnancy have combinatorial adverse impact on both
mother and foetus that further perplexed the situation of diagnosis, treatment, and prevention. This prompted us to evaluate the
status of population at risk of MIP in Hazaribag, Jharkhand, India. Cross-sectional study was conducted over a year at Sadar
Hospital, Hazaribag. Malaria was screened using blood smear and/or RDT. Anaemia was defined as haemoglobin concentration.
Pretested questionnaires were used to gather sociodemographic, clinical, and obstetrical data. The prevalence of MIP was 5.4% and
4.3% at ANC and DU, and 13.2% malaria was in women without pregnancy. Interestingly, majority were asymptomatically infected
with P. vivax (over 85%) at ANC and DU. Peripheral parasitemia was significantly associated with fever within past week, rural
origin of subjects, and first/second pregnancies in multivariate analysis, with the highest risk factor associated with fever followed
by rural residence. Strikingly in cohort, anaemia was prevalent in 86% at ANC as compared to 72% at DU, whereas severe anaemia
was 13.6% and 7.8% at ANC and DU. Even more anaemia prevalence was observed in MIP group (88% and 89% at ANC and DU),
whereas severe anaemia was 23% and 21%, respectively. In view of observed impact of anaemia, parasitemia and asymptomatic
infection of P. vivax during pregnancy and delivery suggest prompt diagnosis regardless of symptoms and comprehensive drug
regime should be offered to pregnant women in association with existing measures in clinical spectrum of MIP, delivery, and its
outcome.

1. Introduction million deaths annually [2]. Plasmodium vivax, the most

widespread parasite causing human malaria, is responsible
Malaria in tropical regions, which is caused by the protozoan for estimated 130–435 million infections annually and is the
parasites Plasmodium falciparum and Plasmodium vivax, is major cause of malaria in most of Asia and Latin America
responsible for 515 million clinical cases [1] and 1 to 3 [3]. Although P. vivax infection is commonly considered to
2 BioMed Research International

be much more benign than Plasmodium falciparum infection, for alternative and effective interventions. The diagnosis of
historical evidence suggests significant mortality associated malaria during pregnancy is complicated by several factors,
with P. vivax malaria in the preantimalarial era [4], and death including multistage pregnancy terms lacerated with dimin-
caused by P. vivax malaria has been increasingly recognized ished immunity, increased susceptibility of severe diseases,
over the past few years [3, 5]. Hazaribag, the region under various obstetric complications, splenic and placental seques-
investigation, was primarily dominated by P. vivax whereas tration of parasites, various forms of anaemia, and variation
some buffering, bordering, and adjoining regions have lower in patient presentation. Thus, development of prompt and
prevalence of P. falciparum and mixed infection. The other accurate diagnosis is an important goal of MIP research.
human infecting Plasmodium parasites, like P. ovale, P. malar- P. falciparum malaria during pregnancy is a well-
iae, and P. knowlesi, are the rarest in Indian isolates and these known cause of maternal and fetal morbidity and mortality.
parasites neither were observed during our investigation nor Although P. vivax infection has received less attention than P.
have been reported previously from Jharkhand. falciparum infection, it is clearly an important contributor to
The emergence and spread of drug resistance to com- both maternal anaemia and low birth weights [20–23] where
monly used chemotherapeutics are major factors contribut- they frequently coexist. However, of 50 million pregnancies
ing to this increasing burden and most of the mortality occurring each year in countries where malaria is endemic,
and morbidity are borne by children and pregnant women. approximately one-half occur in areas where P. vivax malaria
Pregnant women and their infants are susceptible to common is endemic [14]. Although P. vivax infection during pregnancy
and preventable infectious diseases including malaria but has been recognized for many years [20], the impact of such
are woefully left unscreened and untreated. According to infection during pregnancy has been assessed only recently.
an estimate, approximately 125 million pregnant women In series from Thailand and India, women with P. vivax
worldwide are exposed to the risks of malaria in pregnancy infection were more commonly anaemic and delivered lower
(MIP) each year, resulting in 200,000 infant deaths [6]. birth weight neonates, compared with uninfected women,
Every year, in India, 28 million pregnancies take place but the effects were less pronounced than those associated
with 67,000 maternal deaths (Registrar General of India, with P. falciparum infection [21, 22]. In both studies, P. vivax
Sample Registration System, Special Bulletin on Maternal infection was most common during the first pregnancy, and
Mortality in India, 2004-06), with 1 million women left the prevalence of such infection peaked early during the
with chronic ill health and 1 million neonatal deaths [7]. second trimester.
Pregnancy is an event of immunologic tolerance, whereby a Limited and past MIP studies in India have demon-
woman accepts the implantation of the fetal allograft in her strated the important contribution of malaria to maternal
uterus; initiating a gestation phase becomes physiologically and neonatal morbidity and mortality [21, 23, 24]. Although
susceptible and vulnerable to malaria infection. Pregnant preliminary results from earlier studies carried out primarily
women with relatively lower levels of previously acquired in central India suggest that both P. falciparum and P.
immunity are particularly at high risk of the most severe vivax are associated with adverse pregnancy outcomes, these
complications of malaria during pregnancy, such as cerebral studies primarily focused on symptomatic pregnant women
malaria, severe malaria anaemia, abortions, intrauterine fetal infected with vivax [21, 25]. Relatively little information is
death, premature delivery, stillbirths, and maternal and infant available from India about vivax associated malaria during
mortality [6, 8, 9]. In malaria endemic areas, pregnant women pregnancy, particularly from Jharkhand, an understudied and
are more susceptible to Plasmodium infections than their tribal dominant region with perennial malaria transmission
nonpregnant peers. The adverse outcomes of these infections zone where malaria is rampant and causing sizable annual
are primarily felt by primigravidae [10, 11], although, in areas malaria deaths, second to Orissa in India as per the latest
of low or unstable transmission, women of all gravidities may observations published by Dhingra et al. [26] and Hussain
be equally at risk [11]. Pregnant women are 3 times more et al. [27], which reflects the importance of the area and
likely to suffer from severe disease as a result of malarial its necessity of undertaking extensive investigation in terms
infection compared with their nonpregnant counterparts and of malarial pathology concerned and by Hamer et al. [23]
have a mortality rate from severe disease that approaches 50% reflecting the malaria during pregnancy associated with an
[12, 13]. increased risk of neonatal and infant mortality.
In spite of severe and fatal consequences of malaria Thus, in view of the limited information on asymptomatic
during pregnancy for the mother, foetus, and newborn and vivax infection during pregnancy in India, it prompted us
child, the harmful effects can be substantially prevented to investigate with an objective to better define the estimate of
and reduced [14] either by using available interventions or MIP, the prevalence of asymptomatic malaria, and the relative
through appropriate treatment upon early and stringent diag- contribution of P. falciparum and P. vivax during pregnancy
nosis [15–17]. Because malaria infection during pregnancy is and at delivery. To the best of our knowledge, such profile,
often asymptomatic, the most common control strategy is epidemiological association, and clinical correlation have not
intermittent preventive treatment during pregnancy (IPTp), been investigated before on isolates of malaria in pregnancy
designed to clear any malaria infection present at the time of from Hazaribag, Jharkhand, among malaria endemic regions
treatment and also to provide posttreatment prophylaxis to of India. Most significantly, our investigation will be the first
prevent infection for a period of weeks. However, increasing report attempting to evaluate the interplay among anaemia,
concern of widespread resistance of commonly used anti- pregnancy, and asymptomatic malaria, stratified according to
malarial drugs [18, 19] over the globe has opened the avenues clinical groups in adult population residing in a perennial
BioMed Research International 3

Hazaribag, perennial malaria with low transmission

Sahibganj
Godda

Pakaur

Kodarma
Deoghar
Giridih Dumka
Garhwa Chatra
Palamau
Hazaribag
Dhanbad
Bokaro

Lohardaga

Ranchi

Gumla
Purbi
Singhbhum
Pashchimi
Singhbhum

Map of Jharkhand showing study site with red colour

Figure 1: Map of Jharkhand with study site, Hazaribag shown in red.

transmission zone with a codominance of P. vivax and an endemic with stable transmission of malaria, with a total
P. falciparum prevalent region. Thestudy was conducted at of 230 686 malaria cases reported in 2009, of which 39.53%,
Hazaribag in the state of Jharkhand in east India, with the 52.64%, and 7.83% were due to P. falciparum, P. vivax, and mix
ultimate goal of enhancing the development of evidence- infection, respectively [29]. The present study was carried out
based policies to reduce the burden of disease due to MIP in in Hazaribag district, considered to be a malaria endemic area
this region of India. in the state of Jharkhand.
Hazaribag (total population according to 2011 census is
2. Methods 1,734,005) is selected to represent a rural-cum semiurban
district with low but perennial transmission of malaria.
2.1. Study Sites/Design and Population. This study consisted Hazaribag had a yearly average SPR of 7.3% for symptomatic
of cross-sectional surveys conducted in three units, that is, individuals over the last three years, with P. falciparum,
antenatal care units (ANCs), delivery units (DUs), or the P. vivax, and mix infection accounting for 14%, 73%, and
inpatient antepartum ward of Sadar Hospital in Hazaribag 13% of the cases, respectively [30]. The majority of the
districts of Jharkhand, India (Figure 1). Jharkhand had a indigenous population is mix of tribals, schedule caste,
yearly average slide positivity rate (SPR) for symptomatic schedule tribes, and other castes, exceptionally typical social
individuals of 6.8% over the last three years with P. fal- stratification having gender disparity. Moreover, the district
ciparum, P. vivax, and mix infection accounting for 44%, and state lie in the tropical zone with an annual rainfall
44%, and 7% of the cases, respectively [28]. The province of of 1234.5 mm with favorable geoclimatic and ecological
Jharkhand in eastern India is one such area where malaria conditions conducive for perennial malaria transmission.
is rampant. The complexity and magnitude of malaria in the The climatic conduciveness of the investigated district can
central eastern part of India deserve special mention and be best visualized in the self-explanatory Supplementary
attention as the central eastern state contributes 15–20% of Figure-1A (see Supplementary Material available online
total malaria cases in the country as per the Draft on National at http://dx.doi.org/10.1155/2015/740512). Most interestingly,
Policy on Tribals by Government of India, 2005. The investi- with the monthly climatic temperature when compared with
gation is conducted in the Jharkhand state emphasizing tribal monthly malaria episode, we observed significant correlation
dominant area (total population according to 2001 census is between ambient temperature and subsequent rise and fall
31 463 866), and the state of Jharkhand is selected to represent in malaria episode as shown in Supplementary Figure-1B.
4 BioMed Research International

The recent (2010–2012) data on malaria epidemiology has Table 1: Parasitaemia, reported fever, and anaemia among pregnant
been analyzed during investigation in this project and we women attending antenatal clinics and delivery units.
observed the increasing trend of malaria episodes as shown in
Antenatal clinics Delivery units
Supplementary Figure-2A-C, despite consistent interventions
and preventive measures implemented by various national 𝑛 = 1271 𝑛 = 870
and international bodies. 𝑁 (%) 𝑁 (%)
Thus, the selected study district is meant to provide a Peripheral parasitaemia
representation of typical conditions that would be found in Overall 68 (5.4) 37 (4.3)
malaria endemic districts of Jharkhand. Falciparum 3 (0.23) 2 (0.22)
The District Level Household and Facility Survey con- Vivax 59 (4.6) 32 (3.67)
ducted between December 2007 and April 2008 revealed that Mixed 6 (0.47) 3 (0.34)
56% of women had at least one antenatal clinic (ANC) visit By gravidity
and 18% overall had institutional deliveries including 59% Primigravid 21/423 (4.9) 11/338 (3.2)
in urban areas but only 13% in rural settings [31]. Sadar Secundigravid 38/578 (6.6) 15/209 (7.1)
Hospital, the district hospital for Hazaribag district, serves a Multigravid 9/270 (3.3) 11/323 (3.4)
predominantly rural population and has a separate obstetric Report of fever within 1 week 167 (13.1) 93 (10.6)
unit with 40 beds, with a high volume of annual deliveries Anaemia 1093 (86) 626 (72)
ranging from an average of 4800 to 5500 per year in 2010 to Severe anaemia 148/1093 (13.6) 49/626 (7.8)
2013. The Sadar Hospital also has a high volume of ANC visits
including an average of 5200 to 6600 per year from 2010 to
2013. respectively. In the delivery unit, 870 pregnant women were
screened and enrolled as shown in schematic flow chart in
Supplementary Figure-3. All the women at each attendance
2.2. Screening and Enrollment. The study had two compo-
underwent clinical investigations, parasite slide examination,
nents with recruitment targeted to all the women presenting
and measurement of auxiliary body temperature before
to antenatal care unit (ANC) and delivery units (DUs). For
enrollment and we found 68 and 37 MIP cases at ANC
the ANC component, pregnant women aged ≥17 years who
and DU, respectively. In ANC, we found 59, 3, and 6 cases
reported to the study site for routine care were screened
of P. vivax, P. falciparum, and mix infection, respectively,
and enrolled; those were willing and consented to participate
whereas at DU, we found 32, 2, and 3 cases of P. vivax, P.
in our study. For the DU component, women aged ≥18
falciparum, and mix infection, respectively, at Sadar Hospital,
years who presented for delivery and were willing to provide
Hazaribag (Table 1). The controls for malaria in pregnancy
written informed consent were enrolled. Inclusion in the
were malaria in women without pregnancy group in addition
study protocol was based on the considerations like residency
to healthy women; those are without pregnancy having no
and availability status in the study region, no history of
known diseases including malaria at the time of sampling.
hereditary diseases and/or no known severe disease at the
time of conceiving and/or at first ANC attendance, voluntary
and consented participation in our study, and no immediate 2.3. ANC Procedures. Trained study personnel interviewed
illness due to other infectious diseases or malaria in precon- the enrolled women and collected information on sociode-
ception and/or during present pregnancy at the time of first mographic characteristics (i.e., date of birth, socioeconomic
attendance at ANC. Exclusion from study was based on either status, and literacy), reproductive history including gravid-
refusal to give signed consent or unwilling for sampling, ity, history of fever and antimalarial drug use, and use
clinically suspected or identified cases of HIV and hepatitis of antimalarial prevention measures. A complete physical
B infection, and stringently those who are apparently and at examination including the determination of gestational age
first sight so weak due to unknown reason compounded by was assessed by palpation of uterine fundus height combined
pregnancy that may not sustain sampling stress and may lead with information on last menstrual period; measurement of
to undesired complications. auxiliary temperature with digital thermometer and other
Detailed strategy of enrollment, sampling procedures, vital signs was also performed. Peripheral venous blood
and broad groups were as described; recruitment and enrol- (3–5 mL) was collected from all the attendees for malaria
ment took place from September 2012 to December 2013. blood film preparation, rapid diagnostic test (RDT), and
Of 1890 pregnant women screened during their ANC visits, haemoglobin determination apart from other biochemical
1746 were willing to understand our study protocol, out of and molecular investigations. Women with positive RDT
which 1715 consented and agreed on peripheral sampling results or who were anaemic were referred immediately to
and 31 refused to participate in the study. Thus, we enrolled the hospital physician for treatment. The hospital staffs were
1715 subjects, interviewed by trained technical staff, and, informed of additional parasitaemic individuals identified
upon pregnancy screening report and based on other clinical through blood smears so that they could be appropriately
investigations, divided them into the two broad groups, that treated.
is, pregnant and nonpregnant women group consisting of
1271 and 444 subjects, respectively. The nonpregnant group 2.4. DU Procedures. Pregnant women enrolled at the DUs
was subdivided into women with malaria and healthy women were interviewed, with data collection focused on sociode-
without malarial complications, consisting of 227 and 217, mographic and anthropometric characteristics, obstetric
BioMed Research International 5

complications, history of fever and antimalarial use during 2.7. Study Definitions. Severe malaria was defined as a
pregnancy and the use of antimalarial prevention measures, malaria attack associated with any of the following: cerebral
birth outcome, and mode of delivery. Peripheral venous malaria, severe anaemia, renal failure, pulmonary oedema,
blood (3–5 mL) was collected after delivery for malaria blood hypoglycaemia, shock, spontaneous bleeding, or repeated
film preparation and/or rapid diagnostic test (RDT) and convulsions [35]. Maternal height and weight were taken at
haemoglobin determination apart from other biochemical the first visit to ANC and DU; based on this information, the
and molecular investigations. Women with positive RDT or body mass index (BMI) was calculated as weight (kg) divided
blood smear results were referred for treatment. Apart from by the squared height (meters); a low BMI was defined as a
malaria prevalence study in DU, we have also collected clin- BMI < 22.0 kg/m2 . A documented fever was defined as an
ical and demographic data and samples based on the mode auxiliary temperature ≥37.5∘ C.
of delivery, that is, normal, caesarean, and stillbirth delivery,
and further on the mode of birth/delivery outcome, that is, 2.8. Ethics Statement and Subject Consent. All human blood
preterm, postterm, and term delivery; details were presented samples used in this study were collected after obtaining
in Supplementary Table-1. To assess the gestational age, we written consent from the study participants under protocols
mainly adopted the simplest method, that is, symphysis- activities approved by the Institutional Ethics Committee
pubis fundal height (SFH) measurement (also known as (IEC) of the Vinoba Bhave University, Hazaribag, Jharkhand,
palpation of uterine height measurement), most widely used and human ethical guidelines as reflected in the guide-
method over the globe especially in resource poor settings lines of the Medical Ethics Committee, Ministry of Health,
like ours. Assessments were performed by trained nurses Government of India. Present study does not involve any
followed by gynaecologist. However, in case of any undesired minor/children. Thus, signed and written approval was given
measurement or dought over positioning of foetus, they were by adult subject herself. All study participants were included
confirmed by ultrasound to record the gestational ages. only after informed consent. The study protocol and consent
proposal are approved from IEC, VBU, having memo number
2.5. Laboratory Procedures. Thick and thin smears prepared VBU/R/888/2012, dated 05-06-2012.
from peripheral blood of ANC and DU subjects were Giemsa-
stained and examined under high power. The parasite density 2.9. Data Management and Analysis. All clinical, demo-
was evaluated by counting the number of asexual forms of graphic, and anthropometric information were carefully
parasites for every 200 leukocytes, assuming a leukocytes checked for correctness and inconsistencies were resolved
count of 8000 leukocytes/𝜇L of blood [32]. The thin film before analysis. Data were entered in MS-Excel and analyses
was used to identify the Plasmodium species. All slides were were performed using SPSS version 16 (SPSS Inc., Chicago, IL,
cross-checked using stringent diagnostic criteria to diagnose USA) and Graphpad Prism version 5.0 (GraphPad Software,
Plasmodium infection with our trained technical staff. The Inc., CA, USA). For comparisons of means between two
commercial (RDT kit) First Response Malaria pLDH/HR2 groups of subjects, Student’s 𝑡-test was used for evaluating
combo test kits (Premier Medical Corporation, Mumbai, significance for normally distributed data and when data
India) were also used as per the manufacturer’s guideline as were not normally distributed; nonparametric tests (Mann-
a screening tool for diagnosing malaria in pregnant women. Whitney 𝑈) test were used to analyze the data. Categori-
We have used the PCR technique also to diagnose malaria but cal data are presented as frequency counts (percent) and
in selective samples not in all the samples due to budgetary compared using the Chi-square or Fisher’s exact statistic
constraint. The selective samples were all the MIP positive as appropriate. Continuous data are presented as means (±
samples at ANC and DU verified by PCR, those subjects standard error) and compared using the 𝑡-test or analysis of
variance as appropriate. The age of the recruited subject was
who were disputed on microscopy and RDT also verified by
between 18 and 37 years, whereas mean age was 26.7 years.
PCR, and clinically most suspected cases with strong sign and
We have presented participants’ ages in ranges based on their
symptoms but microscopically negative samples were also
responses (Supplementary Table-1). Risk factors for either P.
verified by PCR. falciparum or P. vivax parasitemia were evaluated by uni-
variate analysis and then adjusted for significant predictors
2.6. Haemoglobin Concentration. Haemoglobin (Hb) levels in multivariate analysis. Simple and multiple logistic regres-
were recorded at the first ANC and DU visit. Determining sions were used to analyze potential risk factors associated.
the concentrations of haemoglobin (Hb) was performed Precisely, to investigate the association between the various
in peripheral blood samples using a portable HemoCue independent variables (selecting only strong epidemiological
haemoglobinometer (HemoCue AB, Ängelholm, Sweden) as and biological plausibility for association) and malaria para-
stated by the manufacturer. The concentration of Hb was sitemia, we began by performing simple logistic regressions
recorded on the study questionnaire and double-checked by with each independent variable. Next, we applied multiple
the laboratory technician. Women were classified as anaemic backward logistic regression models and all covariables
(Hb < 11 g/dL) and then categorized as being moderately to present in univariate were kept in model, independent of
severely anaemic, with haemoglobin <8 g/dL and <7 g/dL, their significance, in univariate analysis due to their possible
respectively, as the primary outcome, and being mild to relevance in the final results; thus, we could analyze their
nonanaemic (Hb ≥ 9 g/dL) according to [33, 34]. possible influence when considered together with the other
6 BioMed Research International

variables. Similar strategies were followed for factors associ- level of formal education (Supplementary Table-1). All were
ated with haemoglobin and anaemia during pregnancy and nonsmokers (100%) and nearly all spoke Hindi (97.2%).
malaria in pregnancy; risks were assessed using haemoglobin Most owned their own home (73.9%) and were involved
or anaemia as dependent variables and all other factors in household work (84.3%); a minority engaged in farming
as independent variables. The differences were considered (14.6%). Study participants had attended a median of three
statistically significant when the 𝑝 value obtained was <0.05. ANC visits (range 0–9) and about slightly less than two-thirds
were primigravidae and secundigravidae (Supplementary
3. Results Table-1). The majority of pregnant women reported having
untreated bed nets in their homes and using them recently
3.1. Antenatal Clinics. Most pregnant women attending ANC but ITN ownership was uncommon (Supplementary Table-
were in the 18 to 38 years of age range and had some level of 2). Only three women were taking chemoprophylaxis for
formal education (Supplementary Table-1). The vast majority malaria and none knew the name of the medication that they
of participants were Hindi speaking (97.6%) and nonsmoking were taking. Only 4.3% of the women enrolled at the DUs
(98.7%). Most owned their own home (75.4%) and were had peripheral parasitemia (either a positive blood smear or
engaged in household work (76.7%) with a small proportion RDT). P. falciparum was identified in 5.4% (2/37), P. vivax in
involved in farming (12.3%). They had attended a median of 86.5% (32/37), and mixed infection in 8.1% (3/37). The mean
one ANC visit (range 0–9) during their current pregnancy density of parasitemia in the women with positive blood
and almost one-third of the attendees were primigravidae smears was 16,395 asexual forms/𝜇L (range 870–65,000). The
(33.3%). Slightly more than half of participants presented peripheral parasitemia density was significantly higher in
to the ANC in the latter half of pregnancy whereas 44.6% primigravid women than in those who had one or more
presented prior to 20 weeks. Less than half of the participants prior pregnancies (mean ± SD of 36, 600 ± 9, 743 versus
reported taking iron/folate supplements (46.3%) while 33.2% 7, 532 ± 4623 asexual forms/𝜇L, resp.; 𝑝 = 0.002). Pregnant
were taking multivitamins. In terms of malaria prevention women with peripheral parasitemia were more likely to have
activities, most pregnant women reported having untreated either a self-reported fever or fever measured at enrollment
bed nets in their homes and using them recently, but very than those who were aparasitaemic (36.4% versus 9.2%, 𝑝 =
few had ITNs (Supplementary Table-2). Similarly, only 9 of 0.005). A sizable proportion of women presenting to the
the women were taking prophylaxis for malaria and most of rural origin were parasitaemic as compared to semiurban and
them (7/9, 78%) were unable to identify the drug they were urban origin and this difference was significant (OR 4.36,
taking and the rest (two), who were able to identify the drug, 95% CI 2.48–7.32, and 𝑝 = 0.0001) (Table 2). Primigravidae
were taking chloroquine. and secundigravidae also were more likely to be parasitaemic,
A positive diagnostic test for malaria was obtained in and difference was significant (OR 4.23, 95% CI 2.15–8.42,
5.4% (68/1271) of the total cohort (Table 1). Blood smears and 𝑝 = 0.0001). Asymptomatic malaria infections were
for malaria were positive in 4.3% of pregnant women while present in 70% of women with peripheral parasitemia (26/37)
an additional 14 (1.1%) women had positive RDTs. The mean as compared to 30% symptomatic infection (11/37). Pregnant
density of parasitemia in the 54 women with positive blood women with peripheral parasitemia were more likely to have
smears was 63,236 asexual forms/𝜇L (range 600–489,000). P. either a self-reported fever or fever measured at enrollment
falciparum was identified in 4.4% of parasitaemic individuals than those who were aparasitaemic (28.3% versus 9.2%, 𝑝 =
while P. vivax was found in 86.8% and 8.8% of infections 0.004).
were mixed. Peripheral parasitemia was over four times more As observed in the ANC participants, most episodes
likely among women living in rural areas when compared of parasitemia occurred in July to September during the
with those from urban or semiurban subjects (OR 4.36, 95% monsoon season. For DU participants with peripheral par-
CI 2.48–7.32) and among primigravidae and secundigravi- asitemia, 83.7% had anaemia as compared to 47.6% of those
dae relative to multigravidae (OR 4.23, 95% CI 2.15–8.82). who did not have parasitemia (𝑝 = 0.004). More women with
Parasitaemia was more commonly encountered in pregnant peripheral parasitemia had severe anaemia (5.7%) than those
women who had a history of fever within the week prior to without parasitemia (2.6%) and the difference was significant
enrollment or were febrile at the time of the study visit (4.2% (𝑝 = 0.02).
versus 2.3%, 𝑝 = 0.02). The majority of positive malaria tests Multivariate analysis revealed a significant association
occurred from July to January with the greatest number in between peripheral parasitemia and primigravidae and
between August and October, corresponding to the monsoon secundigravidae, fever within the last week, and semiurban
season. Further multivariate analysis was performed in order and rural residency status as shown in Table 2.
to identify the association between specific demographic,
socioeconomic, and malaria prevention activities and the 3.3. Association between Pregnancy and Asymptomatic P. vivax
risk of parasitemia. Among pregnant women attending with Haemoglobin. Anemia is the most prominent hema-
ANCs, first/second pregnancies, fever in the past week, and tological manifestation of malaria infection. Hemoglobin
residence in rural areas were significantly associated with concentration is the best characterized method and well
peripheral parasitemia as shown in Table 2. accepted indicator for diagnosis of anemia and assessment
of severity. In addition to this, it is regarded as one of the
3.2. Delivery Units. Like the ANC cohort, most pregnant most serious global public health problems which prompted
women attending DUs were aged 20–36 years and had some us to investigate the status of hemoglobin and severity of
BioMed Research International 7

Table 2: Factors associated with peripheral parasitemia during malaria in pregnancy using univariate and multivariate analysis.

Peripheral parasitemia % Adjusted OR (95% CI) p Adjusted OR (95% CI) p

(Positive/total)
Factors at ANC
1st/2nd pregnancies 6.3 (64/1001) 4.45 (2.32–9.61) 4.23 (2.15–8.42)
0.0001 0.0001
3rd or greater pregnancies 1.4 (4/270) 1 1
Age < 20 7.2 (12/166) 1.43 (0.34–3.76) 1.31 (0.26–2.84)
0.052 0.076
Age ≥ 20 5.0 (56/1105) 1 1
Fever within past week 16.1 (27/167) 4.42 (3.64–8.21) 4.62 (3.73–9.83)
0.002 0.001
No fever within past week 3.7 (41/1104) 1 1
Bed net use∗ 7.6 (42/563) 1.12 (0.27–2.47) 1.37 (0.48–3.24)
0.072 0.084
No bed net use 6.7 (26/374) 1 1
Rural 7.1 (61/857) 4.21 (1.53–5.21) 4.36 (2.48–7.32)
0.003 0.0001
Not rural 1.7 (7/414) 1 1
Tribal caste 6.3 (23/363) 1.26 (0.64–2.96) 1.42 (0.81–3.75)
0.054 0.12
No tribal caste 4.9 (45/908) 1 1
No formal education 6.1 (22/357) 1.22 (0.42–2.46) 1.34 (0.68–3.92)
0.065 0.084
Formal education 5.0 (46/914) 1 1
Factors at DU
1st/2nd pregnancies 5.8 (32/547) 3.9 (0.97–11.56) 3.62 (0.94–7.83)
0.004 0.001
3rd or greater pregnancies 1.5 (5/323) 1 1
Age < 20 8.2 (28/109) 2.32 (1.32–9.37) 2.47 (1.17–10.63)
0.062 0.14
Age ≥ 20 3.6 (9/761) 1 1
Fever within past week 13.9 (13/93) 4.47 (1.25–12.42) 4.43 (1.38–11.57)
0.0001 0.0001
No fever within past week 3.1 (24/777) 1 1
Bed net use∗ 5.3 (27/503) 1.97 (0.83–7.62) 1.62 (0.58–6.39)
0.084 0.27
No bed net use 2.7 (10/367) 1 1
Rural 7.1 (29/405) 4.22 (0.41–4.51) 3.87 (0.78–13.62)
0.003 0.0001
Not rural 1.7 (8/465) 1 1
Tribal caste 5.5 (14/251) 1.51 (0.56–3.92) 1.74 (0.83–5.38)
0.053 0.59
No tribal caste 3.7 (23/619) 1 1
No formal education 5.3 (17/321) 1.46 (1.23–3.17) 1.62 (0.87–4.63)
0.57 0.21
Formal education 3.6 (20/549) 1 1
∗
ITN use was not evaluated in this model since ITN were very rarely used and because of quite lesser awareness about ITN among women.

anemia in Jharkhand population, as anaemia is particularly associated sign and symptoms in various studies including
high for women with no education (74%), women from the community based epidemiological studies; and based on the
scheduled tribes (85%), and women in the two lowest wealth prevalence of sign and symptoms, we interestingly observed
quintiles (over 70%). The prevalence of anaemia among in our study that 70.6% (48/68) of the positive cases of
adults in Jharkhand is higher than in almost all other states malaria in pregnancy subjects at ANC were asymptomatic
in India (national family health survey, NFHS-3 India, 2006). with peripheral parasitemia compared to 29.4% symptomatic
Anaemia was prevalent among ANC participants whereas MIP cases, whereas 75.7% were asymptomatic cases with
severe anaemia was reasonably observed in the investigated peripheral parasitemia compared to 24.3% symptomatic
cases (Supplementary Table-1). More than two-thirds of the infection during malaria in pregnancy at DU. Based on the
DU participants were anaemic whereas 7.8% had severe data collected on sign and symptoms from the pregnant
anaemia (Table 1). Of these ANC and DU participants, the women attendees at ANC and DU subjects, we performed
prevalence of mild, moderate, and severe anaemia is shown positive predictive value (PPV) (Table 3) and multivariate
in Figures 2(a)–2(d). (Table 4) analysis to further consolidate our observation and
to explore the association between symptoms and malaria
3.4. Association of Asymptomatic Infection with Malaria infection during pregnancy. For positive predictive value
during Pregnancy at ANC and DU Subjects. Clinical malaria (PPV), fever, history of fever, body pain, headache, dizziness,
cases are suspected and investigated on the basis of malaria vomiting, and convulsions were evaluated at ANC and DU
8 BioMed Research International

Table 3: Positive predictive value (PPV) of clinical signs and symptoms for Plasmodium vivax infection.

𝑁 Observed value (OV) (%) Positive 95% CI in

predictive value (PPV) (%) proportion of PPV (%)
Sign/symptoms at ANC
Fever 54 4.2 26 23.5–28.4
History of fever 167 13.1 45 42.2–47.7
Headache 114 8.9 32 29.4–34.5
Body pain 15 1.2 18 15.8–20.1
Dizziness 29 2.3 21 18.7–23.2
Vomiting 22 1.7 23 20.3–25.3
Convulsions 13 1.1 12 10.2–13.7
Sign/symptoms at DU
Fever 43 4.9 36 32.8–39.1
History of fever 93 10.6 47 43.6–50.3
Headache 172 19.7 33 29.8–36.1
Body pain 23 2.6 26 23.1–28.9
Dizziness 19 2.2 19 16.3–21.6
Vomiting 31 3.5 27 24.1–29.9
Convulsions 14 1.6 21 18.2–23.7

Table 4: Association between signs/symptoms and malaria infection using multivariate analysis.

𝑛/𝑁 (%) OR (95% CI) p value

Sign/symptoms at ANC
No 937/1203 (77.8) 1
Any symptoms 0.14
Yes 20/68 (29.4) 1.3 (0.9–1.9)
No 1138/1203 (94.5) 1
Fever 0.0003
Yes 11/68 (16.1) 2.9 (1.6–5.4)
No 1031/1203 (85.7) 1
History of fever 0.14
Yes 14/68 (20.5) 1.4 (0.8–2.3)
No 1076/1203 (89.4) 1
Headache 0.13
Yes 11/68 (16.1) 1.5 (0.8–2.6)
No 1168/1203 (97.1) 1
Dizziness 0.16
Yes 4/68 (10.1) 1.9 (0.7–5.5)
No 1178/1203 (98) 1
Vomiting 0.21
Yes 3/68 (4.4) 2.1 (0.6–6.8)
Sign/symptoms at DU
No 623/833 (74.7) 1
Any symptoms 0.9
Yes 9/37 (24.3) 0.9 (0.5–1.7)
No 784/833 (94.1) 1
Fever 0.01
Yes 5/37 (13.5) 2.7 (1.2–6.1)
No 770/833 (98.6) 1
History of fever 0.01
Yes 7/37 (18.9) 2.5 (1.2–5.1)
No 655/833 (98.6) 1
Headache 0.46
Yes 6/37 (16.2) 0.7 (0.3–1.5)
No 792/833 (95.1) 1
Dizziness 0.12
Yes 4/37 (10.8) 2.1 (0.8–5.6)
No 775/833 (93.1) 1
Vomiting 0.12
Yes 5/37 (13.5) 1.9 (0.8–4.5)
𝑛 = observed, 𝑁 = total considered subjects, and OR= odds ratio.
BioMed Research International 9

15 15

Level of haemoglobin (gm/dL)

Level of haemoglobin (gm/dL)

∗∗∗
∗∗∗ ∗∗∗
10 10 ∗∗∗
∗∗∗ ∗∗∗

5 5

0 0
Nonanaemic Mild Moderate Severe Nonanaemic Mild Moderate Severe
Anaemia in healthy group of subjects Anaemia in malaria in pregnancy group of patients at ANC
(a) (b)
15 15

Level of haemoglobin (gm/dL)

Level of haemoglobin (gm/dL)

∗∗∗ ∗

10 ∗∗∗ 10 ∗∗∗
∗∗∗ ∗∗∗

5 5

0 0
Nonanaemic Mild Moderate Severe Nonanaemic Mild Moderate Severe
Anaemia in women with malaria group of patients at ANC Anaemia in malaria in pregnancy group of patients at DU
(c) (d)

Figure 2: Level of haemoglobin as classified anaemia in malaria infected subjects screened at antenatal care (ANC) unit and delivery unit
(DU) in stratified group as (a) anaemia in healthy group of subjects, (b) malaria in pregnancy group of patients among ANC attendees, (c)
women with malaria group of patients without pregnancy, and (d) malaria in pregnancy group of patients among DU attendees. Data is
presented as mean and error bar represents the plus or minus SE ∗ 𝑝 ≤ 0.01, ∗∗ 𝑝 ≤ 0.001, and ∗∗∗ 𝑝 ≤ 0.0001 compared with nonanaemic
women using paired 𝑡-test through Graphpad Prism version 5.0.

as shown in Table 3. Almost all the predictive values for were not significantly associated except fever and history of
respective symptoms were observed to be very much low fever which were significantly associated with incidence of
except for history of fever, which is relatively higher than malaria as shown in Table 4. Thus, based on the observation
the others only, despite being the highest among all at both and analysis, we can infer that majority of the sign and
ANC and DU. However, the positive predictive value for symptoms have not been shown or trended to be significantly
history of fever at DU was slightly higher than ANC. None associated, except fever and/or history of fever that have some
of the predictive value for any sign and symptoms was degree of significant association with malaria in pregnancy at
neither nearly 50% or even above (Table 3). The prevalence ANA and DU in multivariate analysis. The absence of higher
of observed values (%) and frequencies (𝑁) for all the signs percentage of positive predictive value for all the symptoms
and symptoms were also presented in Table 3. Further, in as well as lower prevalence of observed value and frequency
applying multivariate model, we analysed any symptoms, can also be regarded as an indicative of nonassociation of sign
fever, history of fever, headache, dizziness, and vomiting at and symptoms with incidence of malaria during pregnancy at
ANC and DU as shown in Table 4. We observed that presence both ANC and DU. As majority of subjects were infected with
of any symptoms, history of fever, headache, dizziness, and vivax strain as described earlier (Table 1) both at ANC and
vomiting were not significantly associated with incidence of DU, thus, view of nonassociation of sign and symptoms with
malaria during pregnancy at ANC, whereas only fever was the incidence of malaria during pregnancy can be coined and
found to be significantly associated at ANC as shown in corroborated with asymptomatic Plasmodium vivax infection
Table 4. However, in case of DU subjects, all the symptoms in the present study both at ANC and DU.
10 BioMed Research International

3.5. Risk Factors Associated with Anaemia in Overall Study as far as the outcome of the project is concerned. However,
Cohort and Malaria in Pregnancy at ANC and DU Subjects. our results of higher prevalence of malaria in pregnancy are
Multivariate logistic regression showed that malaria infec- in accordance with the earlier observations (ranging from
tion, ferritin, iron, haemoglobin, and formal education were 1.7% to 20%) across India [21, 23, 36, 37]. Most of these
significantly associated with a higher risk of anaemia in studies focused on pregnant women with selective approach,
overall cohort (𝑁 = 1271 at ANC and 𝑁 = 870 at DU) as well tend towards screening for mostly febrile, or had a recent
as in malaria in pregnancy at ANC (𝑁 = 68) and DU (𝑁 = history of fever cases and thus may have had a selection
37) subjects as presented in Table 5. The highest (adjusted bias towards expecting higher malaria rates. This approach,
odds ratio in multivariate analysis) risk factor associated with targeting malaria diagnostic and treatment for symptomatic
anaemia was observed with haemoglobin level, followed by pregnant women, is consistent with India’s National Vec-
presence of malaria infection in both malaria in pregnancy tor Borne Disease Control Programme guidelines [38]. In
and overall study cohort at ANC and DU as shown in Table 5. contrast, all pregnant women were evaluated in the current
However, ANC subjects have shown relatively higher risk study regardless of classical symptoms and, interestingly,
ratio association of anaemia with haemoglobin and malaria we observed well that over 70% of the pregnant women
compared to DU subjects (Table 5). Comprehensive results in ANC and DU had asymptomatic malaria during preg-
of univariate and multivariate analysis are shown in Table 5. nancy, which suggests the region specific intervention. The
broader spectrum of screening strategies was in accordance
4. Discussion with earlier investigation in this region [23], though our
observations are notably varied from their observations as
The estimate of malaria in pregnancy continues to be grave far as asymptomatic malaria during pregnancy is concerned.
concern for community reproductive health care manage- Infection from P. vivax in pregnancy has conventionally been
ment across the tropical region including India, up to the level regarded less severe as compared to P. falciparum malaria.
of pacifying the concept of healthy mother and healthy baby Interestingly, we reported that majority were infected with P.
of National Family Welfare Programme. In fact, situation is vivax infection during malaria in pregnancy. This observation
much more aggravated in developing countries like India, may be attributed to the lack of placental sequestration in
where poverty, illiteracy, geographical diversity, socioeco- P. vivax infection and the parasite tropism for reticulocytes
nomic disparities, and multiple pregnancies take their toll of accounting for a milder form of anaemia [39, 40].
mother’s health. The higher prevalence of malaria in women without
Among the prominent findings of the present study, we pregnancy and with pregnancy, irrespective of ANC and
found 5.4% and 4.3% malaria during pregnancy at ANC and DU attendees’ location of residence, that is, rural, urban,
DU, respectively, as compared to only 1.8% and 1.7% at ANC and semiurban, suggests that Hazaribag and its buffering
and DU, respectively, reported by Hamer et al. [23] from the zone have perennial rate of malaria transmission. Therefore,
series of cross-sectional and multicentric study in Jharkhand. populations of all age groups including pregnant women are
However, our study design is slightly broader than the earlier at potential risk of getting malaria infection even irrespective
investigation from Hamer et al. [23] in terms of subject of transmission season, though peak was observed in post-
stratification, as we have also taken into account women with monsoon season. Apart from this, there is significant lack of
malaria without pregnancy, and the prevalence of malaria was education, general awareness towards health issues, congenial
found to be 13.2%, which itself reflects the importance of the environmental factors for vector growth and survival, and
investigated region and population under malaria sensitive most importantly sizable population lack access to vector
zone. However, our study lacks the difference of investigating control methods or limited access to antimalarial drugs. Peo-
placental malaria. The pondering difference in the prevalence ple residing below poverty line linking to malnutrition and
of malaria during pregnancy between our investigations, anaemia may be plausible reasons for various opportunistic
though we have selected only one centre in one district, that infectious diseases including malaria.
is, Hazaribag, Jharkhand, as compared to three centres from Interestingly, insecticide residual spray (IRS) of home,
two districts, that is, Ranchi and Gumla of Jharkhand by which is usually conducted by government agencies, was
Hamer et al. [23], may be attributed to various other reasons reported more in rural areas as compared to urban and
but primarily linked to the selection of study sites. As Ranchi semiurban zone of Hazaribag, though its seasonal usage of
is an urbanized capital with lots of high-tech development IRS in those areas regarded as perennial transmission may
in and around the city, local and buffering populations are be suggestive of vector resistance and subsequent higher
much more educated, aware of practicing healthy life style prevalence of disease. Our observations warrant the potential
and various diseases prevention strategies including malaria, need to enhance the IRS and distribution of ITNs in and
having high socioeconomic status, excellent with a choice around the investigated district.
of health facility compared to the rest of the districts of We report that P. vivax is associated with a high burden
Jharkhand state, and most importantly less malarious than of anaemia and remarkable severe anaemia during pregnancy
almost 20 other districts of Jharkhand as far as malarial and malaria in pregnancy in endemic population of Haz-
epidemiology is concerned in last ten years [29]. Thus, aribag.
selected site by Hamer et al. [23] may not be the true Overall, there was significant burden of anaemia among
representation of the malaria scenario and rather burden of women in Jharkhand and particularly during pregnancy [23].
malaria during pregnancy in Jharkhand but absolutely true Our observations regarding anaemia are in accordance with
 Table 5: Risk factors for anaemia in pregnant women (PW) and malaria during pregnancy (MIP) using univariate and multivariate analysis.
PW PW PW PW PW MIP MIP MIP MIP MIP
Number Crude OR (95% CI) p Adjusted OR (95% CI) p Number Crude OR (95% CI) p Adjusted OR (95% CI) p
Factors at ANC
Malaria∗∗
No 1203 1 1 9∗ 1 1
BioMed Research International

0.0001 0.0002 0.0001 0.0001

Yes 68 2.7 (1.4–3.8) 2.8 (1.2–3.4) 59¥ 3.1 (1.7–5.3) 3.4 (1.9–6.5)
Ferritin (ng/mL)
<50 117 1 1 5 1 1
0.002 0.001 0.0001 0.0004
≥50 1154 1.8 (1.3–2.3) 2.2 (1.6–3.5) 63 2.1 (1.6–3.3) 2.4 (1.7–4.1)
Iron (𝜇g/dL)
≥40 236 1 1 10 1 1
0.006 0.003 0.001 0.0001
<40 1035 1.7 (1.6–2.7) 1.9 (1.8–3.4) 58 2.2 (1.5–3.3) 2.3 (1.2–2.7)
Haemoglobin (Hb) (g/dL)
Hb > 11 217 1 1 0.0003 19 1 1
0.0001 0.0001 0.0002
Hb < 11 1054 3.8 (2.3–8.7) 4.2 (2.1–8.8) 0.0002 49 4.8 (1.7–8.1) 5.4 (1.6–8.6)
Education
NFE 357 1 1 13 1 1
0.003 0.001 0.0001 0.0001
FE 914 2.1 (1.4–2.9) 2.3 (1.7–3.9) 55 2.2 (1.6–3.5) 2.6 (1.3–3.4)
Factors at DU
Malaria∗∗
No 833 1 1 5∗ 1 1
0.0001 0.0002 0.001 0.0001
Yes 37 2.1 (1.2–2.5) 2.4 (1.6–3.8) 32¥ 2.2 (1.4–3.1) 2.8 (1.7–4.7)
Ferritin (ng/mL)
<50 205 1 1 7 1 1
0.004 0.0003 0.0001 0.0002
≥50 665 1.4 (1.2–1.7) 1.7 (1.4–2.3) 30 2.1 (1.8–3.8) 2.3 (1.5–3.5)
Iron (𝜇g/dL)
<40 683 1 1 31 1 1
0.002 0.0002 0.006 0.0003
≥40 187 1.9 (1.6–3.1) 2.2 (1.3–2.9) 6 2.3 (1.5–3.5) 2.5 (1.3–3.3)
Haemoglobin (Hb) (g/dL)
Hb > 11 173 1 1 8 1 1
0.0001 0.0001 0.001 0.0001
Hb < 11 697 3.1 (1.8–5.6) 3.6 (2.1–7.6) 29 4.2 (1.9–7.8) 4.8 (1.6–7.7)
Education#
NFE 321 1 1 11 1 1
0.004 0.0002 0.002 0.0001
FE 549 1.6 (1.1–1.8) 1.8 (1.4–2.6) 26 1.7 (1.5–2.6) 2.1 (1.7–3.6)
PW = pregnant women, MIP = malaria in pregnancy, ANC = antenatal care unit, and DU = delivery unit; # NFE = no formal education, FE = formal education. ∗∗ In case of MIP, the comparison is between P. vivax
versus P. falciparum and mix infection; ∗ P. falciparum + mix infection, ¥ P. vivax.
11
12 BioMed Research International

the findings from other studies in Jharkhand [23], across [52, 55, 58, 59]. However, authors did not establish the extent
India [41, 42], and most relevant study by Nosten et al. to which anaemia contributed to those deaths.
[43] in which they have demonstrated that women who had The very low rate of ownership of insecticide treated
malaria at any time were more likely to be anaemic than bed nets (ITNs) and awareness suggests that this component
women without malaria. Among multifactorial involvement of the enhanced malaria control programme (EMCP) has
in malarial anaemia are included haemolysis of parasitized not effectively reached this vulnerable population although
erythrocytes and increased clearance of nonparasitized ones it was encouraging to find that many households had bed
as well as an inadequate bone marrow response [44]. It nets and that they were used on a regular basis. However, our
has been suggested that pregnancy has also confounding investigation suggests that approaches for ITN distribution
association with anaemia and malaria [43, 45] and P. vivax and enhancing community awareness about the importance
has shown 2-fold higher risk of moderate anaemia than of their use need to be addressed as similarly observed and
uninfected subject [46, 47]. proposed by earlier investigation in adjacent region by Hamer
Thus, regardless of transmission level and the level of et al. [23].
prepregnancy immunity against malaria, maternal anaemia Despite the change in drug policy in 2008 in the studied
remains the most frequent adverse consequences of malaria state (Jharkhand), the availability and implementation of
during pregnancy [48]. The symptoms and complications combination therapy, that is, artesunate plus sulfadoxine
of malaria in pregnancy vary according to malaria trans- pyrimethamine, are a major concern. It has been well docu-
mission intensity in the given geographical area and the mented that chloroquine resistance has been rising in India
individual’s level of acquired immunity. In low-transmission [60–63]; this drug was recommended for malaria prophylaxis
settings, where women of reproductive age have relatively in pregnant women in high risk areas as reported by Hamer
little acquired immunity to malaria, MIP is associated with et al. [23], though it has been discontinued since recom-
anaemia, an increased risk of severe malaria. This may mendation. Presently, quinine sulphate was recommended
lead to spontaneous abortion, stillbirth, prematurity, and for malaria prophylaxis in pregnant women in the investi-
low birth weight [49, 50]. In such settings, malaria affects gated area irrespective of gestational age. However, this is
all pregnant women, regardless of the number of times partly in accordance with The Directorate of National Vector
they have been pregnant. In pregnant women, additional Borne Disease Control Programme (NVBDCP) and current
sequestration of malaria infected erythrocytes occurs in the WHO guidelines suggesting prophylaxis for trimester based
placenta. Pregnant women therefore suffer disproportion- treatment of malaria during pregnancy as quinine for first
ately from severe anaemia as a result of infection [14]. Our trimester and subsequently ACTs in the second and third
observation is also substantiated by the fact that the majority trimester of pregnancy (http://www.nvbdcp.gov.in/Doc/Dia-
of malaria infections in pregnancy remain asymptomatic gnosis-Treatment-Malaria-2013.pdf). Since the intensity of
or paucisymptomatic and yet are a major cause of severe transmission and the prevalence of malaria in pregnant
maternal anaemia and low birth weight, especially in the first women in Jharkhand are comparatively lesser than in
and second pregnancies [22, 23]. In areas with stable but low many areas in sub-Saharan Africa, notably, sulfadoxine pyri-
transmission like our investigated area and certainly in areas methamine was commonly used in Africa as intermittent
with unstable and exceptionally low transmission, infections preventive treatment of pregnant women (IPTp) [15], which
can become severe in all gravidae groups because most may not be presently suggestive priority for Jharkhand to
women of childbearing age in these regions have low levels of implement IPTp though it may be considered as an alter-
prepregnancy and pregnancy-specific protective immunity to native to the priority failure strategy. The top priority for
malaria [14]. Jharkhand should be on preventive measures like improved
High prevalence of anaemia was observed and strongly availability, awareness and uses of ITNs by pregnant women,
correlated with asymptomatic P. vivax infection. This preva- and well organised IRS system. In addition, we recommend
lence is similar to that reported by Brutus et al. [47] and much more stringent and frequent screening and diagnosis
Douglas et al. [46, 51]. Recent work has shown that, in Papua using conventional and RDTs irrespective of classical malaria
New Guinea and Papua, Indonesia, mixed infection causes symptoms to pregnant women in all the trimesters. Most
more severe haematological impairment than infection with importantly, in view of sizable prevalence based on hospital
either species alone [52–54]. The impact of Plasmodium study and potential risk for population at large in the
vivax infection on haemoglobin concentration varies from investigated region, we are also suggestive of dedicated active
negligible to dramatic [52, 55–57]. The clinical consequences and passive surveillance for MIP at the community level
of the reduction in haemoglobin depend on the haemoglobin like regular malaria surveillance under India’s NVBDCP.
concentration prior to infection. Although the spectrum This strategy alone could potentially reduce the burden
of anaemia seen with vivax infection is reasonably well of MIP while limiting the potential for antimalarial resis-
documented, the clinical, developmental, and socioeconomic tance to develop due to the widespread use of drugs for
consequences are largely unknown. Population-based esti- chemoprophylaxis. The present study shows two important
mates of mortality in severely anaemic individuals with vivax findings; that is, the observed predominant prevalence of
malaria have not been established but recent studies from asymptomatic infections differs from that of symptomatic
Latin America, New Guinea, and the Indian subcontinent disease and marked alteration in haematological indices
have identified deaths in patients with severe vivax anaemia during P. vivax infection with pregnancy synergistically
BioMed Research International 13

contributes to maternal anaemia in a low and perennial (iii) There should be priority consideration of early case
malaria transmission setting. detection and management of asymptomatic preg-
One major limitation of this study is that we were unable nant women through restructuring the need of active
to access the placental malaria due to limitation of our and passive surveillance strategy in endemic as well as
study design. Although the study was restricted to women in nonendemic zone.
delivering in the hospital, a sizable number of (more than (iv) In view of the asymptomatic prevalence of coinfec-
60%) women give birth outside Sadar Hospital, Hazaribag. tion, we need to further strengthen and emphasize
Further, a longitudinal study instead of cross-sectional the robust screening strategies, curative attention, and
one would have provided better estimate of MIP in this region safe treatment facilities at the community level health
and probably our study design may have given underestimate centres.
as compared to actual risk population. This has also been
apprehended and suggested by Hamer et al. [23]. Despite Further, integrated investigation is desperately needed to
these limitations, this study provides important data on understand the magnitude and prevalence of asymptomatic
the epidemiology and clinical implications of vivax malaria malaria infection linking as an important infected reservoir
during pregnancy and delivering at Hazaribag district Sadar to continue malaria transmission. Precisely, our finding high-
Hospital. In spite of restricted and facility based study, lights the public health importance of integrated genus-wide
we preferentially covered marginalized, tribes, and remote malaria control strategies using diagnostic tests including
population of the investigated rural-cum semiurban district, RDTs and ensuring the availability of safe and effective drugs
Hazaribag. The majority of the districts and particularly for the treatment of pregnant women in areas of Plasmodium
malaria endemic districts in Jharkhand have similar geo- coendemicity.
graphical, socioeconomic, demographic, literacy, and basic
amenities including health facility and awareness. Thus, Conflict of Interests
our observation may be utilized for baseline information
for further comprehensive and multicentric study design, Sneh Lata is employed in respective government organiza-
in strengthening MIP associated preventive measures and tion, which is directly providing health services to the com-
screening methods within the state of Jharkhand. munity; however, this does not alter the authors’ adherence
to policies on sharing data and materials. The authors have
declared that no competing interests exist.
5. Conclusion
As the global control and elimination of malaria progress, Authors’ Contribution
P. vivax is set to become the dominant Plasmodium species
[64]; yet, the health, developmental, and socioeconomic Mohammad Sohail and Mohammad Raziuddin conceived
consequences of vivax malaria and vivax-associated anaemia and designed the experiments. Mohammad Sohail, Shayan
have received very little attention. Salient findings of this Shakeel, Shweta Kumari, Aakanksha Bharti, and Faisal Zahid
study are as follows: performed the experiments. Mohammad Sohail, Ajay Kumar
Sharma, Shadab Anwar, Krishn Pratap Singh, and Maza-
(i) There is high prevalence of anaemia during pregnancy hirul Islam analyzed the data. Mohammad Sohail, Shayan
and in delivering women in the malaria endemic Shakeel, Shweta Kumari, Aakanksha Bharti, and Sneh Lata
population of Hazaribag, Jharkhand. designed the clinical studies and collected samples. Moham-
(ii) Prevalence of anaemia is significantly associated with mad Raziuddin, Ajay Kumar Sharma, Vahab Ali, Maza-
Plasmodium vivax infection during pregnancy and in hirul Islam, Tridibes Adak, Pradeep Das, and Sneh Lata
delivering women. contributed reagents/materials/analysis tools. Mohammad
Sohail, Mohammad Raziuddin, and Krishn Pratap Singh
(iii) The most significant observation was the high preva-
wrote the paper. Mohammad Sohail, Shayan Shakeel, Shweta
lence of asymptomatic P. vivax infection at both ANC
Kumari, and Aakanksha Bharti equally contributed to the
and DU.
paper.
Taken together, these observations are quite indicative and
emphasize the need to actively diagnose and treat malaria Acknowledgments
infection during ANC visit in the areas of perennial transmis-
sion. Additionally, in view of the sizable population at risk in The active support from Mr. Arjun Prasad and Mrs Devyanti
this malaria endemic region of India, we are suggestive of few Devi at Sadar Hospital, Hazaribag, in clinical sample col-
priority practice amendments and reorientation of policies lection is gratefully acknowledged. The authors thank the
for MIP prevention strategies: supporting staff team, particularly microscopists at Sadar
Hospital, Hazaribag, for their untiring dedication and excep-
(i) There is an urgent need to enhance the ITN availabil- tional skill in examining the blood smears. The authors thank
ity, use, and awareness both in population and health all the OPD physicians at Sadar Hospital, Hazaribag, for
worker. their expertise and dedication in providing health care to the
(ii) Distribution of ITNs at first ANC visit will be lucrative community, particularly to the poor and the underprivileged.
alternative for preventive strategy. The authors would like to thank Dr. Birenda Kumar Gupta,
14 BioMed Research International

Assistant Professor, University Department of Zoology, [15] C. Menéndez, U. D’Alessandro, and F. O. ter Kuile, “Reducing
Vinoba Bhave University, Hazaribag, India, for helpful dis- the burden of malaria in pregnancy by preventive strategies,”
cussion during project implementation. The authors also wish The Lancet Infectious Diseases, vol. 7, no. 2, pp. 126–135, 2007.
to acknowledge honourable Vice Chancellor of Vinoba Bhave [16] F. O. Ter Kuile and R. W. Steketee, “Intermittent preventive
University for support and kind assistance for the work. This therapy with sulfadoxine-pyrimethamine during pregnancy:
research was supported by Dr. D. S. Kothari Postdoctoral seeking information on optimal dosing frequency,” The Journal
Grant under UGC, Government of India (Letter no. F.4- of Infectious Diseases, vol. 196, no. 11, pp. 1574–1576, 2007.
2/2006 (BSR)/13-690/2012 (BSR) dated 25th of May, 2012) [17] F. O. Ter Kuile and S. J. Rogerson, “Plasmodium vivax infection
and partly supported by ISID-Small grant, USA, Fall-2012 during pregnancy: an important problem in need of new
to Mohammad Sohail. Shayan Shakeel as Junior Research solutions,” Clinical Infectious Diseases, vol. 46, no. 9, pp. 1382–
Fellow and Shadab Anwar and Krishn Pratap Singh as 1384, 2008.
Senior Research Fellows (Ph.D. students) were supported by [18] A. Bardajı́, Q. Bassat, P. L. Alonso, and C. Menéndez, “Inter-
the UGC, DBT, and DST, Government of India fellowship, mittent preventive treatment of malaria in pregnant women
respectively. The funders had no role in study design, data and infants: making best use of the available evidence,” Expert
collection and analysis, decision to publish, or preparation of Opinion on Pharmacotherapy, vol. 13, no. 12, pp. 1719–1736, 2012.
the paper. [19] P. E. Duffy and M. Fried, “Malaria in the pregnant woman,”
Current Topics in Microbiology and Immunology, vol. 295, pp.
169–200, 2005.
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