Subclinical malaria among pregnant women living in refugee settlements in Northern Uganda

Winnie Kibone; Felix Bongomin; Sarah Lebu; Stephen Ochaya; Ritah Nantale; Jerom Okot; Byron Awekonimungu; Rachel Beardsley; Chimdi Muoghalu; Musa Manga

doi:10.1177/20499361241296002

Subclinical malaria among pregnant women living in refugee settlements in Northern Uganda

Ther Adv Infect Dis. 2024 Nov 6:11:20499361241296002. doi: 10.1177/20499361241296002. eCollection 2024 Jan-Dec.

Authors

Affiliations

¹ Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, P. O. Box 166, Uganda.
² Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda.
³ Department of Environmental Sciences and Engineering, Gillings School of Public Health, University of North Carolina at Chapel Hill, NC, USA.
⁴ Faculty of Health Sciences, Busitema University, Mbale, Uganda.
⁵ Department of Environmental Sciences and Engineering, the University of North Carolina at Chapel Hill, 0300 Michael Hooker Research Center, 135 Dauer Drive, Campus Box # 7431, Chapel Hill, NC 27599, USA.

Abstract

Background: Malaria during pregnancy contributes to significant perinatal morbidity and mortality, accounting for almost 25% of global maternal mortality. However, the epidemiology and risk factors for subclinical malaria among pregnant women living in refugee settlements is poorly understood.

Objective: To determine the prevalence and predictors of subclinical malaria among pregnant women in refugee settlements in Northern Uganda.

Design: We conducted a multi-center, cross-sectional study.

Methods: The study was conducted between April and June 2023 and involved pregnant women aged 18-45 years attending routine antenatal care (ANC) at three health facilities serving refugee communities in Adjumani district, Uganda. We collected sociodemographic, environmental, maternal, and obstetric factors using a structured questionnaire. Both CareStart Malaria HRP-2/pLDH (Pf/Pan) combo rapid diagnostic test (RDT) and blood smear microscopy with 3% Giemsa staining were simultaneously performed on samples from each patient. Logistic regression analysis identified factors independently associated with subclinical malaria, reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

Results: We enrolled 304 pregnant women, with a mean age of 25 years. In total, 68.8% (n = 209) had lived in the settlement for over 12 months, 25.7% (n = 78) were primigravida, and 1.0% (n = 3) were living with HIV. Malaria prevalence was 5.3% (n = 16) by RDT and 3.2% (n = 10; seven Plasmodium falciparum and three P. malariae) by microscopy. Only 4 (25.0%) of the RDT-positive cases were also positive by microscopy (Cohen's kappa: 0.278-Fair agreement). All participants were asymptomatic. Factors associated with higher odds of subclinical malaria included primiparity (aOR: 2.79, 95% CI: 1.25-6.25, p = 0.013), ⩾4 ANC visits (aOR: 2.41, 95% CI: 1.34-4.34, p = 0.003), and residence in the settlement for less than 12 months (aOR: 2.54, 95% CI: 2.0-3.22, p < 0.001). Living in the settlement for over 3 years, being primigravida, and being married were associated with 68%, 50%, and 68% lower odds of subclinical malaria, respectively (aOR: 0.32, 95% CI: 0.13-0.79, p = 0.014; aOR: 0.50, 95% CI: 1.22-5.52, p = 0.016; aOR: 0.32, 95% CI: 0.13-0.78, p = 0.012).

Conclusion: Our study reveals the high prevalence of subclinical malaria among pregnant women in refugee settlements, particularly among primiparous women and recent arrivals. The poor agreement between RDT and microscopy suggests the need for dual screening in asymptomatic pregnant women.

Keywords: Northern Uganda; antenatal care; asymptomatic malaria; maternal health; refugee settlement.

Plain language summary

Asymptomatic malaria in pregnant women living in refugee settlements in Northern Uganda Malaria during pregnancy is a major health issue, causing many deaths worldwide. In this study, we aimed to determine the burden and factors that increase the risk of asymptomatic malaria among pregnant women in refugee settlements in Northern Uganda. Using diagnostic methods such as rapid diagnostic tests (RDTs) and microscopy, we tested 304 pregnant women at three health centers serving the refugee communities in Adjumani District between April and June 2023. We found that 5.3% of the women had malaria according to the RDT, and 3.2% had it according to microscopy. Women who were pregnant for the first time, had frequent antenatal visits, or had lived in the camp for less than a year were more likely to have asymptomatic malaria. This study highlights the need for regular malaria testing, even if pregnant women show no symptoms, to better improve their health in refugee settlements.