News & Analysis Global Health More Comprehensive Care Drug-Resistant Malaria Detected for Miscarriage Needed Worldwide in Africa Will Require Monitoring About 1 in 10 women will have a miscar- Evidence in Africa that the malaria parasite riage over a lifetime—a statistic that repre- Plasmodium falciparum has developed sents 23 million pregnancies lost annually, genetic variants that confer partial resis- or 44 per minute worldwide, according to tance to the antimalarial drug artemisinin is a series of articles in The Lancet. Despite a warning of potential treatment failure on the magnitude, the articles described mis- the horizon, a drug-resistance monitoring carriage as a misunderstood phenomenon study suggested. and called for more comprehensive care to Partial resistance to artemisinin, the cur- prevent and treat miscarriage. rent frontline treatment for malaria, first The 15% of pregnancies that end in a emerged in Cambodia in 2008 and has be- miscarriage can be attributed to risk fac- come common in Southeast Asia, the au- tors including age during pregnancy, smok- thors wrote. Artemisinin is a fast-acting drug ing, stress, air pollution, and exposure to that typically clears the parasite within 3 pesticides, 1 of the studies reported. For days. It’s usually combined with a longer- Miscarriage is a misunderstood phenomenon, repeated miscarriages, which affect about acting drug to kill any remaining parasites. according to a recent series of articles. 2% of women, another study indicated When artemisinin resistance emerged in that progesterone could increase live-birth Asia, resistance to the combination therapy rates and that levothyroxine may decrease soon followed. 2020 when half of essential services had the risk of miscarriage for women with The current study was part of routine been interrupted. subclinical hypothyroidism. Repeated mis- treatment efficacy monitoring, which is rec- However, 94% of countries continue to carriages can be emotionally devastating ommended by the World Health Organiza- report disruptions even though two-thirds and pose a risk of future pregnancy compli- tion. Among 224 children with malaria who of them took steps such as hiring additional cations, the authors noted. In some cul- were tested at 3 sites in Rwanda in 2018, a personnel or expanding home-based care tures, they added, women who are unable worrisome artemisinin-resistance variant or telemedicine services. Although the find- to have children and their partners may was present in 13% of the parasite samples ings are encouraging, WHO Director face discrimination, stigma, and ostracism. analyzed. At 2 sites, lingering P falciparum General Tedros Adhanom Ghebreyesus, Another study in the series recom- detected in about 15% of children 3 days PhD, MSc, said in a statement that “The sur- mended using high-quality ultrasound for after treatment was linked with the variant. vey highlights the need to intensify efforts accurate miscarriage diagnoses and surgi- Although combination therapy remained and take additional steps to close gaps and cal management with vacuum suction highly effective—efficacy ranged from 94% strengthen services.” aspiration as the preferred approach for to 97%—close monitoring of drug resis- Ongoing barriers to care include work- missed miscarriages—those that occur tance in Rwanda and neighboring countries force shortages in two-thirds of the respond- without pain or bleeding. The authors is essential, the authors wrote. ing countries and supply chain disruptions in noted that dedicated early pregnancy “ [O]ur new study shows that resistant about one-third of countries. Half the par- units are emerging as a model of care in isolates are starting to become more com- ticipating countries reported that patients the UK, Canada, Australia, and other coun- mon and most importantly, are associated are still reluctant to seek care because of tries. These units should be equipped with clinical implications (delayed parasite mistrustorfearofinfection.Primarycareand with appropriate medications, ultrasound clearance),”lead author Aline Uwimana, MD, rehabilitative, palliative, and long-term care machines, efficient blood test process- of the Rwanda Biomedical Centre in Kigali, remained the most heavily affected by con- ing, and staff who are properly trained in Rwanda, said in a statement. tinuing disruptions, according to the sur- ultrasound scanning, giving bad news, and vey. Malaria services and childhood immu- providing psychological support, the Despite Improvements, COVID-19’s nizations also face ongoing challenges. authors wrote. Health Care Disruptions Persist “Prolonged immunization disrup- Co–lead author of the series, Siobhan The COVID-19 pandemic’s disruption of es- tions will have long-term consequences Quenby,MD, of the University of Warwick in sential health care services has eased some- for children’s health,” UNICEF Executive the UK, said in a statement that many what, according to the World Health Orga- Director Henrietta Fore said in the WHO women who’ve had a miscarriage are ad- nization (WHO). Its latest survey showed statement. “The time to catch up is vised only to try again. “That is not good that about a third of those services world- now.” − Bridget M. Kuehn, MSJ enough, and we must ensure women are wide were still disrupted during the first Note: Source references are available in embedded iStock.com/nicoletaionescu properly supported.” quarter of 2021—an improvement from hyperlinks in the article text online. jama.com (Reprinted) JAMA June 15, 2021 Volume 325, Number 23 2335 © 2021 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021.