Le paludisme chez la femme enceinte
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Le paludisme chez la femme enceinte

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Le paludisme chez la femme enceinte - Conférence de la 1ère édition du Cours international « Atelier Paludisme » - JAMBOU Ronan

Le paludisme chez la femme enceinte - Conférence de la 1ère édition du Cours international « Atelier Paludisme » - JAMBOU Ronan

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Le paludisme chez la femme enceinte Le paludisme chez la femme enceinte Presentation Transcript

  • Le paludisme chez la femme enceinte Elements de reflexions Jambou R Atelier Paludisme IPM 2003
  • WHOAt least 24 millionpregnancies are threatenedeach year in Africa andmalaria causes up to 15percent of maternal anaemiaand about 35 percent ofpreventable low birth-weight. Malaria attack Placental infection Atelier Paludisme IPM 2003
  • Paludisme et grossesseLa grossesse induit une augmentation du nombre d’accèsJusqu’à deux mois après l’accouchement => Projet Dielmo(Niagne et al) Atelier Paludisme IPM 2003
  • Paludisme et grossesse(WHO 2001) Atelier Paludisme IPM 2003
  • Placental infection Intervillous spaces ( fibrine and parasites)Syncicio-trophoblast Fœtal blood(pigment in cells) Atelier Paludisme IPM 2003
  • Classification of infections1 uninfected no pigment no parasite2 chronic infection only pigment in cells or villosities3 chronic – active infection parasites + pigment in cells or in tissu4 recent infection Parasites in intervillous spaces without pigment or fibrine (Blumer et al ) Atelier Paludisme IPM 2003
  • Quel est le poids du paludisme chez les femmes enceintes en zone urbaine ?? Projet d’étude – Dakar 2000 (AdS) / 2003 (FSP) Atelier Paludisme IPM 2003
  • Area of study Atelier Paludisme IPM 2003
  • Population studiedGuediawaye- DakarSuburb of Dakar - population 600 000 inhabitantslow and seasonal transmission of malaria around water collections (Niayes)exchange of populations with the rural areasomen attending the maternity “Roi Baudoin” of Guediawaye for delivery-from July to December- Living in the periphery of Dakar- no travel declared the two months prior to the delivery- placental infestation (positive detection of HRP II antigen in the placental blood) Atelier Paludisme IPM 2003
  • 700 delivering women 10% HRP2 positive placenta Parasiteamia in blood / weight of birth 4000 3600 3200 Weight 2800 2400 2000 1600 1200 male 800 0,1 1,0 10,0 100,0 1000,0 female Parasiteamia % Atelier Paludisme IPM 2003
  • k-means cluster analysis of venous and placental parasiteamia 3,5 3,0 2,5 2,0 1,5Placenta 1,0 0,5 Cl 1 0,0 Cl 2 Cl 3 -0,5 -0,4 0,2 0,8 1,4 2,0 2,6 3,2 Cl 4 Venous blood Atelier Paludisme IPM 2003
  • Pregnancy and Classification of the infection 174000 153600 Weight of birth Haemoglobin3200 132800 112400 92000 71600 Non-Outlier Max1200 1 2 3 4 Non-Outlier Min 5 1 2 3 4 CLASSIFICATION 75% 25% CLASSIF Median 11 46 42 9 Number of pregnancy 38 7 34 AGE 5 30 26 3 22 1 uninfected 2 chronic infection 1 18 3 chronic/active 14 4 recent infection -1 1 2 3 4 1 2 3 4 CLASSIF Atelier Paludisme IPM 2003
  • Typage des parasites(Contamin et al) Atelier Paludisme IPM 2003
  • 1016 9 MSA2 3D7 MSA1 MAD2014 8 712 610 58 4 36 24 12 0 <= 310 450 > 5900 <= 275 550 > 800 9 8 10 7 MSA1 RO33 9 6 8 MSA2 FC27 5 7 4 6 3 5 2 4 1 3 0 2 <= 310 460 > 610 1 0 7 <= 325 560 > 800 6 MSA1 K1 5 4 3 Placenta 2 1 Venous Blood 0 <= 340 450 > 635 Atelier Paludisme IPM 2003
  • MSP1 MSP 1 and MSP 2 5,5 5,5 Number of alleles 4,5 4,5 3,5 3,5 2,5 2,5 1,5 MSP 2 1,5 0,5 0,5 -0,5 1 10 100 Parasiteamia (blood) -0,5 -1 0 1 2 3 4 5 6 7 Venous blood MSP 1 MSP2 placenta 5,5Number of alleles 4,5 No relation between polymorphism of MSA1 3,5 and MSA2 2,5 1,5 No relation between parasiteamia and polymorphism of MSA2 et MSA1. 0,5 -0,5 1 10 100 Parasiteamia (blood) Atelier Paludisme IPM 2003
  • Comparaison of the two populations - 1Size of MSA2 1+2 = from 719 to 992 bp.FC29 (52,85 %) of parasites4 alleles by woman2,1 alleles by venous sample (1.3 alleles for FC29 and 0.8 for 3D7)54 % of women with different parasites in placenta and blood (by sub typing)20 % of women with only 50 % of identityaverage percent of common allele 14 %.Size of the product MSA1 A+B = from 349 to 687 bpRO33 42,86 % of parasites4,9 alleles by woman (max 8 alleles)2,6 allele by placenta (max 5) : 0.8 for K1 and MAD20 and 0.9 for RO332,2 alleles by venous sample (max 5) : 0.6 for K1 and MAD20 and 1 for RO3362 % of identity between MSA1 A+B products in the placenta and in the blood60 % of women with different parasites in placenta and blood (by sub typing)average percent of common allele 11%. Atelier Paludisme IPM 2003
  • Comparaison of the two populations - 2Correlation between polymorphism of MSA1 in the blood and in the placentaThe number of allele of MSA1 increase in the placenta with the number of pregnancyThe percent of common allele of MSA1 between blood and placenta increasewith the number of pregnancyNo correlation between the total number of alleles of MSA1 or MSA2 and -the type of placental infection -the use of chemoprophylaxis -the number of pregancy-the age of the motherAmplification of PfCRT :- 62 out of 71 placentas 82,5 of mutation in codon CRT76- 54 out of 71 venous sample = 85,7% of mutation in codon CRT76For 51 women with positive amplification in blood and in the placenta11,7% had none similar codon Atelier Paludisme IPM 2003
  • 1 Infection locale du placenta2 pas de relation entredensité parasitaire sur lesyncico-troph et le poids denaissance3 très grand polymorphismedes souches =>quelle signification ? Atelier Paludisme IPM 2003
  • Pourquoi existe t il une infection locale ?? Atelier Paludisme IPM 2003
  • Atelier Paludisme IPM 2003
  • Méthodes d’étude Atelier Paludisme IPM 2003
  • Différents mécanismes d’adhésion Atelier Paludisme IPM 2003
  • Atelier Paludisme IPM 2003
  • Atelier Paludisme IPM 2003
  • (Craig et al) Atelier Paludisme IPM 2003
  • Expression of Variant SurfaceAntigens by Plasmodiumfalciparum Parasites in thePeripheral Blood of ClinicallyImmune Pregnant WomenIndicates Ongoing PlacentalInfection.(Ofori MF, et al) Atelier Paludisme IPM 2003
  • Que faire en Pratique ??1 Développer un vaccin contre l’infection locale ? Atelier Paludisme IPM 2003
  • unstimulated stimulated Atelier Paludisme IPM 2003
  • Atelier Paludisme IPM 2003
  • Quel(s) gène(s) Var pour les parasites placentaires Atelier Paludisme IPM 2003
  • Que faire en Pratique ??1 Développer un vaccin ?2 Prophylaxie et Traitement intermittent ? Atelier Paludisme IPM 2003
  • ProphylaxieDémarche actuelle Prophylaxie par la Chloroquine = 300mg/ sem Recouvrement des coûtsLes problèmes 1 ère CPN tardive = rarement avant le 2eme trimestre Observance faible = lié au coût / motivation faible Résistance émergeante = données incomplètes = dispensaires Atelier Paludisme IPM 2003
  • Les traitements intermittentsEtude du Malawi (depuis 1993) infection placentaire : 32 % à 23 % Faible poids de naissance : 23% à 10%.Proposition : traitement systématique par SP lors des CPNProblème : résistance rapide à la SP artésunate Atelier Paludisme IPM 2003
  • Que faire en Pratique ??1 Développer un vaccin ?2 Prophylaxie et Traitement intermittent ?3 Protéger contre les vecteurs Atelier Paludisme IPM 2003
  • La grossesse augmente le nombre de piqûre Long rang Short rang (with children) (Lindsay S et al) (Ansell J et al) Problème = à quelle heure piquent les moustiques ??? Atelier Paludisme IPM 2003
  • Que faire en Pratique ??1 Développer un vaccin ?2 Prophylaxie et Traitement intermittent ?3 Protéger contre les vecteurs4 prendre en charge les carences (fer-folates) Interaction avec les anti-folates ??5 Améliorer la prise en charge de l’accouchement Atelier Paludisme IPM 2003
  • MIM conference•case management alone is not effective in preventing theadverse effects of malaria• selection of the currently available preventive toolschemoprophylaxis,intermittent treatment andinsecticide-impregnated bednets => determined by local conditions•all women in endemic areas should receive haematinicsduring pregnancy• current strategies may be less effective in HIV+ women Atelier Paludisme IPM 2003
  • MIM conference• appropriate tools are needed to monitor the effectiveness ofcurrent programmes• new methods are needed to improve the implementation andcompliance with control strategies• monitoring the effectiveness of impregnated bednets indifferent endemic settings• the cost-effectiveness of interventions in different settingsneeds to be assessed Atelier Paludisme IPM 2003