Arthropod borne disease: the leading cause of fever in pregnancy on the Thai-Burmese border

Rose McGready, Elizabeth A Ashley, Vanaporn Wuthiekanun, Saw Oo Tan, Mupawjay Pimanpanarak, Samuel Jacher Viladpai-Nguen, Wilarat Jesadapanpong, Stuart D Blacksell, Sharon J Peacock, Daniel H Paris, Nicholas P Day, Pratap Singhasivanon, Nicholas J White, François Nosten, Rose McGready, Elizabeth A Ashley, Vanaporn Wuthiekanun, Saw Oo Tan, Mupawjay Pimanpanarak, Samuel Jacher Viladpai-Nguen, Wilarat Jesadapanpong, Stuart D Blacksell, Sharon J Peacock, Daniel H Paris, Nicholas P Day, Pratap Singhasivanon, Nicholas J White, François Nosten

Abstract

Background: Fever in pregnancy is dangerous for both mother and foetus. In the 1980's malaria was the leading cause of death in pregnant women in refugee camps on the Thai-Burmese border. Artemisinin combination therapy has significantly reduced the incidence of malaria in the population. The remaining causes of fever in pregnancy are not well documented.

Methodology: Pregnant women attending antenatal care, where weekly screening for malaria is routine, were invited to have a comprehensive clinical and laboratory screen if they had fever. Women were admitted to hospital, treated and followed up weekly until delivery. A convalescent serum was collected on day 21. Delivery outcomes were recorded.

Principal findings: Febrile episodes (n = 438) occurred in 5.0% (409/8,117) of pregnant women attending antenatal clinics from 7-Jan-2004 to 17-May-2006. The main cause was malaria in 55.5% (227/409). A cohort of 203 (49.6% of 409) women had detailed fever investigations and follow up. Arthropod-borne (malaria, rickettsial infections, and dengue) and zoonotic disease (leptospirosis) accounted for nearly half of all febrile illnesses, 47.3% (96/203). Coinfection was observed in 3.9% (8/203) of women, mostly malaria and rickettsia. Pyelonephritis, 19.7% (40/203), was also a common cause of fever. Once malaria, pyelonephritis and acute respiratory illness are excluded by microscopy and/or clinical findings, one-third of the remaining febrile infections will be caused by rickettsia or leptospirosis. Scrub and murine typhus were associated with poor pregnancy outcomes including stillbirth and low birth weight. One woman died (no positive laboratory tests).

Conclusion/significance: Malaria remains the leading cause of fever in pregnancy on the Thai-Burmese border. Scrub and murine typhus were also important causes of fever associated with poor pregnancy outcomes. Febrile pregnant women on the Thai-Burmese border who do not have malaria, pyelonephritis or respiratory tract infection should be treated with azithromycin, effective for typhus and leptospirosis.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1. Map of the study area…
Figure 1. Map of the study area including Maela Refugee camp and migrant clinic sites.
Figure 2. Patient flow.
Figure 2. Patient flow.
Figure 3. Complete blood count results (mean…
Figure 3. Complete blood count results (mean and 95% CI) by diagnostic group.
WBC – white blood cells, PLT – platelet, Mal. – malaria. Number at base of platelet column is the sample size for each diagnostic group.

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