BACKGROUND:Infection during pregnancy may affect maternal and infant immunity against childhood diseases. We aimed to evaluate the effects of maternal HIV and malaria on maternal and infant pertussis immunity and placental antibody transfer. METHODS:A prospective study was conducted in mother-infant pairs in Mozambique. Peripheral and cord blood samples were collected for pertussis-specific immune assays. Maternal HIV serostatus and Plasmodium falciparum infection were assessed. The placental transfer was assessed using cord-to-mother ratios of IgG against pertussis toxin (PT), pertactin (PRN) and fimbriae 2/3 (FIM). RESULTS:A total of 270 mother-infant pairs were included: 99 mothers with HIV and 40 mothers with malaria. Pregnant women with HIV showed a reduction in placental transfer [PT: 12.7%, 95% confidence interval (CI): 2.6-21.7, P = 0.015; PRN: 14.6%, 95% CI: 6.3-22.1, P = 0.001; and FIM: 7.5%, 95% CI: -6.6 to 19.7, P = 0.282] compared with women without HIV. A trend toward reduction in IgG transfer was observed among women with malaria (PT: 9.5%, 95% CI: -4.2 to 21.4, P = 0.165; PRN: 5.0%, 95% CI: -7.0 to 15.7, P = 0.394; and FIM: 15.9%, 95% CI: -0.9 to 30.0, P = 0.062) compared with those without. Maternal HIV infection (odds ratio: 4.43, 95% CI: 2.14-9.1; P < 0.001) and high viral load (odds ratio: 4.37, 95% CI: 1.4-12.2; P = 0.033) were associated with impaired placental transfer. CONCLUSIONS:Maternal HIV infection is associated with lower mother-to-infant transfer of pertussis antibodies. While efforts continue in the health care of pregnant women with HIV, interventions such as maternal immunization can be a valuable strategy to prevent pertussis in infants.

Monitoring HIV infection estimates is critical to guide health interventions and assess their impact, especially in highly vulnerable groups to the infection such as African pregnant women. This study describes the trends of HIV infection over eleven years in women attending selected antenatal care (ANC) clinics from southern Mozambique. We performed a secondary analysis of data registered at the ANC clinic of the Manhiça District Hospital and from the Ministry of Health's HIV National Program Registry between 2010 and 2021. HIV incidence was calculated using prevalence estimates. HIV incidence trends over time were obtained by fitting splines regression model. Data from 21,810 pregnant women were included in the analysis. Overall HIV prevalence was 29.3

ObjectiveThe effectiveness of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is threatened by increasing SP resistance in Africa. We assessed the level of SP-resistance markers, and the clinical and parasitological effectiveness of IPTp-SP in southern Mozambique.MethodsP. falciparum infection, antimalarial antibodies and dhfr/dhps SP-resistance mutants were detected by quantitative polymerase chain reaction (qPCR), suspension array technology and targeted deep sequencing, respectively, among 4016 HIV negative women in Maputo province (2016-2019). Univariate and multivariate regression models were used to assess the association between taking the recommended three or more IPTp-SP doses (IPTp3+) and parasitological and clinical outcomes.Results84.3% (3385/4016) women received three or more IPTp-SP doses. The prevalence of quintuple mutants at first ANC visit was 94.2%. IPTp3+ was associated with a higher clearance rate of qPCR-detected infections from first ANC visit to delivery (adjusted odds ratio [aOR]=5.9, 95%CI: 1.5-33.3; p=0.012), lower seroprevalence at delivery of antibodies against the pregnancy-specific antigen VAR2CSADBL34 (aOR=0.72, 95%CI: 0.54-0.95; p=0.022), and lower prevalence of low birth weight deliveries (aOR: 0.61, 95% CI: 0.41-0.90; p=0.013).ConclusionA sustained parasitological effect of IPTp-SP contributes to the clinical effectiveness of IPTp3+ in areas with high prevalence of SP resistance markers.

Background Orphanhood is among the major socio-economic challenges in low- and middle-income countries, but measuring the trends, causes, and consequences of orphanhood on children in these countries has been difficult due to lack of adequate data. This study aimed to provide insights into the trends in prevalence, incidence, causes and consequences of orphanhood on living arrangements and migration of children in Manhiça district, Mozambique. Methods This study presents a descriptive analysis of annual prevalence and incidence of orphans, leveraging data from a Health and Demographic Surveillance System (HDSS) that followed 225,921 children < 18 years during 1998–2021 in Manhiça. It also presents cause-specific proportions of orphans using verbal autopsies. The impacts of orphanhood on living arrangements and migration of children were examined by comparing indices such as household size and composition, and annual rates of migration by orphan status. Results The results show that 8.1% of children had lost at least one biological parent before age 18 years. There were more paternal orphans (51.5%) than maternal orphans (42.1%), and double orphans (6.3%). The prevalence and incidence of orphanhood increased and decreased - with prevalence increasing from 1.8% in 1998 to 6.3% in 2021, after peaking to 9.2% in 2011–2012, a trend that appears to reflect the trend in adult mortality in Manhiça, where the 45q15 increased from 0.40 in 1998 to over 0.65 during 2002–2008, before decreasing in 2009–2021. HIV/AIDS and tuberculosis were the leading causes of orphanhood, with 38.8% of maternal orphans and 30.8% of paternal orphans; followed by other communicable diseases (16.2% and 15.0% of maternal and paternal orphans, respectively). Sixty-seven percent of orphans lived in female-headed households compared to 19.7% of non-orphans. Orphans had higher rates of migration (108.5 per 1,000 person-years) than non-orphans (76.0), particularly among maternal orphans and infants. Conclusions These findings quantify and describe the burden of orphanhood and its evolution over 2.5 decades and suggest a need for targeted interventions to address the socio-economic challenges stemming from orphanhood in Manhiça and, likely, in similar contexts. Furthermore, the study provides crucial insights for future research using this HDSS data, e.g. the assessment of the implications of orphanhood on child health, survival, and marriage.

Routine sampling of pregnant women at first antenatal care (ANC) visits could make Plasmodium falciparum genomic surveillance more cost-efficient and convenient in sub-Saharan Africa. We compare the genetic structure of parasite populations sampled from 289 first ANC users and 93 children from the community in Mozambique between 2015 and 2019. Samples are amplicon sequenced targeting 165 microhaplotypes and 15 drug resistance genes. Metrics of genetic diversity and relatedness, as well as the prevalence of drug resistance markers, are consistent between the two populations. In an area targeted for elimination, intra-host genetic diversity declines in both populations (p = 0.002-0.007), while for the ANC population, population genetic diversity is also lower (p = 0.0004), and genetic relatedness between infections is higher (p = 0.002) than control areas, indicating a recent reduction in the parasite population size. These results highlight the added value of genomic surveillance at ANC clinics to inform about changes in transmission beyond epidemiological data.

Objective: The effectiveness of intermittent preventive treatment of malaria in pregnancy with sulfadoxinepyrimethamine (IPTp-SP) is threatened by increasing SP -resistance in Africa. We assessed the level of SPresistance markers, and the clinical and parasitological effectiveness of IPTp-SP in southern Mozambique. Methods: P. falciparum infection, antimalarial antibodies and dhfr/dhps SP -resistance mutants were detected by quantitative polymerase chain reaction (qPCR), suspension array technology and targeted deep sequencing, respectively, among 4016 HIV -negative women in Maputo province (2016-2019). Univariate and multivariate regression models were used to assess the association between taking the recommended three or more IPTp-SP doses (IPTp3+) and parasitological and clinical outcomes. Results: 84.3% (3385/4016) women received three or more IPTp-SP doses. The prevalence of quintuple mutants at first antenatal care (ANC) visit was 94.2%. IPTp3+ was associated with a higher clearance rate of qPCR-detected infections from first ANC visit to delivery (adjusted odds ratio [aOR]=5.9, 95% CI: 1.5-33.3; p = 0.012), lower seroprevalence at delivery of antibodies against the pregnancy -specific antigen VAR2CSADBL34 (aOR=0.72, 95% CI: 0.54-0.95; p = 0.022), and lower prevalence of low birth weight deliveries (aOR: 0.61, 95% CI: 0.41-0.90; p = 0.013). Conclusion: A sustained parasitological effect of IPTp-SP contributes to the clinical effectiveness of IPTp3+ in areas with high prevalence of SP -resistance markers. (c) 2024 The Author(s). Published by Elsevier Ltd on behalf of The British Infection Association. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

There is a recognised need for innovative methods to elicit the perspective of adolescents on public health issues, particularly when addressing sensitive topics such as the impact of mining projects on their health. Participatory approaches such as "photovoice" allow for deep engagement of vulnerable and marginalised populations, including adolescents. However, few existing studies have used the photovoice method to reflect on issues related to the environment and its impact on public health. To date, no studies have been found that have used photovoice to gain insight into adolescents' perspectives in mining areas. In this paper, we discuss the application of the photovoice method to understand adolescents' perceptions about the impact of mining on their health and well-being in rural areas in Mozambique. The study was conducted in northern and central Mozambique. Photovoice was successfully integrated into eight focus group discussions with adolescent girls and boys aged 15 to 17 years. Several lessons for guiding future research were learned. First, it provided an understanding of the perceived impacts of mining on their health and well-being. Second, photovoice promoted active engagement and interest in the study by the adolescents. Finally, compared to its ability to capture perceptions of physical and environmental aspects affecting adolescents' well-being, the method was less straightforward in revealing their concerns regarding social, relational and community aspects that are less tangible. Programs can make use of photovoice to address health issues without setting adolescents' views and priorities aside, allowing them to influence health decisions on issues that are meaningful to them. Future studies should explore strategies to minimise the role of the power dynamics that affect the engagement and contribution of adolescents in advocating for necessary and meaningful changes. Additionally, it is important to investigate how health programs and policies can help to reduce the impact of existing inequalities.

Background: Natural resource extraction projects (NREPs) might impact the social, economic and health conditions of marginalised and/or vulnerable population groups, such as adolescents. While different types and forms of impact assessments (IAs) have the aspiration to place particular emphasis on potential project-related effects in vulnerable and/or marginalised groups, it remains unclear whether and to what extent health and well-being of adolescents have been considered in IA of NREPs.Methodology: We conducted a scoping review of different sources, including peer-reviewed literature, IA reports, and existing focused IA guidelines to examine whether and how adolescent health and well-being have been addressed in IA of NREPs. We focussed on the peer-reviewed literature, IA reports and IA guidelines.Results: Out of 5055 records identified in the peer-reviewed literature, 32 articles were included in the final analysis. Additionally, 25 IA reports from sub-Saharan African countries and six international IA guidelines were considered. We found that environmental determinants of health were the main feature addressed in peerreviewed publications. Sexually transmitted infections, including HIV/AIDS, were frequently reported health outcomes in NREP areas that affect adolescents. However, the complex interplay between environmental exposures, social status and risk behaviour of adolescents were rarely investigated. Only a few IA reports identified adolescents as a specific vulnerable and/or marginalised group. There was a paucity of specific tools and methodologies in IA guidelines that are tailored to adolescents. Conclusion: The development and use of specific guidance that provides a framework for IA practitioners to identify and mitigate health risks in NREP areas is an essential first step towards implementation and better inclusion of adolescents in current IA practice. This should be complemented by a broad research agenda aiming to expand the current narrow understanding of how NREPs affect the health and well-being of community subgroups, including adolescents.

Mining projects can have adverse effects on public health, potentially impacting the 2030 Sustainable Development Agenda. While environmental impacts are typically addressed through mandatory environmental impact assessments, public health consequences often receive inadequate attention, despite being a major concern for affected communities. Policy instruments for mitigating these public health issues, including health impact assessment (HIA), remain underutilized, particularly in Africa. We conduct a Q-methodology study in Mozambique to (1) identify policy preferences of government, private sector, and civil society stakeholders for regulating public health in large-scale mining projects; and (2) to actively engage local stakeholders in a national-level dialogue on strengthening public health in impact assessment practise. The findings were successfully used to initiate and inform a policy dialogue in cooperation with local public health professionals and public health institutions, as well as policymakers in the respective ministries.

Background Sub-Saharan Africa is the region with the highest burden of malaria and HIV worldwide, being pregnant women the most vulnerable populations. Mefloquine (MQ) for intermittent preventive treatment (IPTp) of malaria in pregnancy has shown to significantly reduce malaria-related adverse maternal outcomes. However, while effective in HIV-uninfected pregnant women, results from an EDCTP-funded placebo-controlled trial assessing the safety and efficacy of IPTp-MQ among HIV-infected pregnant women showed that MQ recipients had a two-fold increased risk of HIV mother-to-child transmission (MTCT) compared to the control group. In this analysis we aimed to determine the antiretroviral (ARV) drug levels among a sub-sample of pregnant women participating in the aforementioned trial by treatment arm. Methods ARV drug levels were determined by UPLC/MS/MS methodology (LLQ 2.5ng/mL, for all drugs) in venous and cord blood samples of 249 pregnant women enrolled from 2010 to 2012 in Manhiça, Southern Mozambique. Results No significant differences in the maternal and foetal levels of nevirapine (NVP), lamivudine (3TC) and zidovudine (AZT) were found across groups. However, maternal levels of NVP tended to be decreased in MQ recipients compared to the placebo one among the subset of women transmitting the HIV to their infants (344.64 [558.99] vs 926.4 [619.67], p=0.054). Conclusion Our findings suggest potential pharmacological interactions between MQ and NVP that warrant caution in the administration of antimalarial drugs to HIV-infected women on ARV treatment.

BackgroundMalaria is one of the significant health problems in the world, and the greatest burden of the disease is concentrated in Africa, which accounts for about 95% of cases. The World Health Organization indicates that early seeking for treatment is crucial to avoid worsening the disease and, consequently, death. This work evaluated the factors that influence early health care-seeking (EHCS) behaviour in children under five years old and the effect of EHCS on hospitalisations.MethodsWe conducted a health facility-based observational longitudinal study over 5 years, starting in January 2015 where confirmed P. falciparum (Pf) malaria cases were identified in an ongoing morbidity surveillance system established in Manhiça district hospital and 5 referral health centres by Manhiça Health Research Centre. Using the first visit for all children that visited a Health Facility (HF) with fever or history of fever in the previous 24 hours and confirmed Pf malaria, we defined EHCS as a visit to an HF within 48h after the onset of fever. We used multilevel logistic regression to identify the factors related to EHCS and the association between EHCS and hospitalisation.ResultsOf 66620 under 15 years old children screened only 1603 meet all inclusion criteria. A kilometre increase in the distance to a health facility reduced the odds of EHCS by 11% (aOR=0.89; CI: [0.83–0.95]; p=0.001). EHCS reduced the odds of hospitalization (aOR=0.56; 95% CI: [0.34 -0.93]; 0.024) and year increase in the year of the visit increased the odds of hospitalization by 66% (aOR = 1.66; 95% CI: [1.41–1.93]; p<0.001).ConclusionIncreasing the distance to HF reduced the likelihood of EHCS, whereas EHCS reduced the risk of hospitalisation. Maulana and Calanga lead the hospitalisation cases in the study area in children with malaria and cases of delay in health care seeking.

Pregnant women attending first antenatal care (ANC) visits represent a promising malaria surveillance target in Sub-Saharan Africa. Here we assessed the spatio-temporal relationship between malaria at ANC (n=6,471), in children at the community(n=9,362) and at health facilities (n=15,467) in southern Mozambique (2016-2019). ANC P. falciparum rates detected by quantitative polymerase chain reaction mirrored rates in children, regardless of gravidity and HIV status (Pearson correlation coefficient [PCC]>0.8, χ²<1.1), with a 2-3 months lag. Only at rapid diagnostic test detection limits at moderate-to-high transmission, multigravidae showed lower rates than children (PCC=0.61, 95%CI[-0.12-0.94]). Seroprevalence against the pregnancy-specific antigen VAR2CSA reflected declining malaria trends (PCC=0.74, 95%CI[0.24-0.77]). 80% (12/15) of hotspots detected from health facility data using a novel hotspot detector, EpiFRIenDs, were also identified with ANC data. The results show that ANC-based malaria surveillance offers contemporary information on temporal trends and the geographic distribution of malaria burden in the community.

Objectives: Malaria is still one of the main reasons for hospitalization in children living in sub-Saharan Africa. Rapid risk stratification at admission is essential for optimal medical care and improved prognosis. Whereas coma, deep breathing, and, to a lesser degree, severe anemia are established predictors of malaria-related death, the value of assessing prostration for risk stratification is less certain. Methods: Here we used a retrospective multi-center analysis comprising over 33,000 hospitalized children from four large studies, including two observational studies from the Severe Malaria in African Children network, a randomized controlled treatment study, and the phase-3-clinical RTS,S-malaria vaccine trial, to evaluate known risk factors of mortality and with a specific emphasis on the role of prostration. Results: Despite comparable age profiles of the participants, we found significant inter- and intra-study variation in the incidence of fatal malaria as well as in the derived risk ratios associated with the four risk factors: coma, deep breathing, anemia, and prostration. Despite pronounced variations, prostration was significantly associated with an increased risk of mortality (P <0.001) and its consideration resulted in improved predictive performance, both in a multivariate model and a univariate model based on the Lambaréné Organ Dysfunction Score. Conclusion: Prostration is an important clinical criterion to determine severe pediatric malaria with possible fatal outcomes.

Mozambique is one of the four African countries which account for over half of all malaria deaths worldwide, yet little is known about the parasite genetic structure in that country. We performed P. falciparum amplicon and whole genome sequencing on 2251 malaria-infected blood samples collected in 2015 and 2018 in seven provinces of Mozambique to genotype antimalarial resistance markers and interrogate parasite population structure using genome-wide microhaplotyes. Here we show that the only resistance-associated markers observed at frequencies above 5% were pfmdr1 -184F (59%), pfdhfr -51I/59 R/108 N (99%) and pfdhps -437G/540E (89%). The frequency of pfdhfr / pfdhps quintuple mutants associated with sulfadoxine-pyrimethamine resistance increased from 80% in 2015 to 89% in 2018 (p < 0.001), with a lower expected heterozygosity and higher relatedness of microhaplotypes surrounding pf dhps mutants than wild-type parasites suggestive of recent selection. pfdhfr/pfdhps quintuple mutants also increased from 72% in the north to 95% in the south (2018; p < 0.001). This resistance gradient was accompanied by a concentration of mutations at pfdhps -436 (17%) in the north, a south-to-north increase in the genetic complexity of P. falciparum infections (p = 0.001) and a microhaplotype signature of regional differentiation. The parasite population structure identified here offers insights to guide antimalarial interventions and epidemiological surveys.

Background Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine is recommended at each antenatal care clinic visit in high-moderate transmission areas. However, its coverage remains unacceptably low in many countries. Community health workers can effectively deliver malaria preventive interventions. The aim of this study was to assess the effect of community delivery of IPTp (C-IPTp) on antenatal care and IPTp coverage. Methods A community-based IPTp administration approach was implemented in four sub-Saharan countries: the Democratic Republic of the Congo (DR Congo), Madagascar, Mozambique, and Nigeria. A quasi-experimental before and after evaluation by cluster sampling was designed where C-IPTp was implemented in selected country areas in different phases. Baseline (before C-IPTp implementation), midline, and endline household surveys were carried out to assess IPTp intake in pregnant women in 2018, 2019, and 2021. Eligible participants of the household survey were women of reproductive age (13-50 years old, depending on the country) that had a pregnancy that ended (any pregnancy regardless of pregnancy outcome) in the 6 months before the interview. For the first baseline surveys, the target population was women who had a pregnancy that ended in the 12 months before the interview. The primary outcome from the household surveys was the proportion of women who reported having received at least three doses of IPTp during pregnancy. The trial is registered at ClinicalTrials.gov, NCT03600844. Findings A total of 32 household surveys were conducted between March 15, and Oct 30, 2018, and data from 18 215 interviewed women were analysed. The coverage of at least three doses of IPTp (IPTp3+) increased after the first year of C-IPTp implementation in all project areas in DR Congo (from 22 center dot 5% [170/755] to 31 center dot 8% [507/1596]), Madagascar (from 17 center dot 7% [101/572] to 40 center dot 8% [573/1404]), and Nigeria ( from 12 center dot 7% [130/1027] to 35 center dot 2% [423/1203]), with increases between 145 center dot 6% (Madagascar) and 506 center dot 6% (Nigeria). IPTp3+ coverage increased between baseline and endline in all districts, except for Murrupula (Mozambique) and ranged between 9 center dot 6% and 533 center dot 6%. This pattern was similar in DR Congo, Madagascar, and Nigeria, and in Mozambique, the increase was lower than the other countries. Antenatal care attendance did not change or increased lightly in all study countries. Interpretation C-IPTp was associated with an increase in IPTp uptake without reducing antenatal care attendance. The strategy might be considered for malaria control in pregnancy.

Background Low-density Plasmodium falciparum infections prevail in low transmission settings, where immunity is expected to be minimal, suggesting an immune-independent effect on parasite densities. We aimed to describe parasite densities in pregnancy, and determine how gravidity and antibody-mediated immunity affect these, during a period of declining malaria transmission in southern Mozambique. Methods We documented P. falciparum infections at first antenatal care visits ( n = 6471) between November 2016 and October 2019 in Ilha Josina (high-to-moderate transmission area), Manhiça (low transmission area), and Magude (pre-elimination area). Two-way interactions in mixed-effects regression models were used to assess gravidity-dependent differences in quantitative PCR-determined P. falciparum positivity rates ( Pf PR qPCR ) and densities, in the relative proportion of detectable infections (pDi) with current diagnostic tests (≥ 100 parasites/μL) and in antimalarial antibodies. Results Pf PR qPCR declined from 28 to 13% in Ilha Josina and from 5–7 to 2% in Magude and Manhiça. In primigravidae, pDi was highest in Ilha Josina at the first study year ( p = 0.048), which declined with falling Pf PR qPCR (relative change/year: 0.41, 95% CI [0.08; 0.73], p = 0.029), with no differences in antibody levels. Higher parasite densities in primigravidae from Ilha Josina during the first year were accompanied by a larger reduction of maternal hemoglobin levels (− 1.60, 95% CI [− 2.49; − 0.72; p < 0.001), than in Magude (− 0.76, 95% CI [− 1.51; − 0.01]; p = 0.047) and Manhiça (− 0.44, 95% CI [− 0.99; 0.10; p = 0.112). In contrast, multigravidae during the transmission peak in Ilha Josina carried the lowest pDi ( p = 0.049). As Pf PR qPCR declined, geometric mean of parasite densities increased (4.63, 95% CI [1.28; 16.82], p = 0.020), and antibody levels declined among secundigravidae from Ilha Josina. Conclusions The proportion of detectable and clinically relevant infections is the highest in primigravid women from high-to-moderate transmission settings and decreases with declining malaria. In contrast, the falling malaria trends are accompanied by increased parasite densities and reduced humoral immunity among secundigravidae. Factors other than acquired immunity thus emerge as potentially important for producing less detectable infections among primigravidae during marked declines in malaria transmission.

BackgroundMalaria is among the top causes of death in adolescent girls (10 to 19 years) globally. Adolescent motherhood is associated with increased risk of adverse maternal and neonatal outcomes. The interaction of malaria, adolescence, and pregnancy is especially relevant in malaria endemic areas, where rates of adolescent pregnancy are high. However, data on burden of malaria among adolescent girls are limited. This study aimed at investigating whether adolescent girls were at a greater risk of experiencing malaria-related outcomes in pregnancy-parasitaemia and clinical disease-than adult women.Methods and findingsAn individual secondary participant-level meta-analysis was conducted using data from 5,804 pregnant women participating in 2 malaria prevention clinical trials in Benin, Gabon, Kenya, Mozambique, and Tanzania between 2009 and 2014. Of the sample, 1,201 participants were adolescent girls with a mean age of 17.5 years (standard deviation (SD) 1.3) and 886 (73.8%) of them primigravidae. Among the 4,603 adult women with mean age of 27.0 years (SD 5.4), 595 (12.9%) were primigravidae. Mean gestational age at enrolment was 20.2 weeks (SD 5.2) and 1,069 (18.4%) participants were HIV-infected. Women were followed monthly until the postpartum visit (1 month to 6 weeks after delivery). This study considered outcomes including clinical episodes during pregnancy, peripheral parasitaemia at delivery, and placental malaria. A 2-stage meta-analysis approach was followed by pooling single multivariable regression results into standard DerSimonian-Laird random-effects models. Adolescent girls were more likely than adult women to present with clinical malaria during pregnancy (incidence risk ratio (IRR) 1.70, 95% confidence interval (CI) 1.20; 2.39, p-value = 0.003, I2 = 0.0%, N = 4,092), peripheral parasitaemia at delivery (odds ratio (OR) 2.28, 95% CI 1.46; 3.55, p-value < 0.001, I2 = 0.0%, N = 3,977), and placental infection (OR 1.97, 95% CI 1.31; 2.98, p-value = 0.001, I2 = 1.4%, N = 4,797). Similar associations were observed among the subgroup of HIV-uninfected participants: IRR 1.72 (95% CI 1.22; 2.45, p-value = 0.002, I2 = 0.0%, N = 3,531) for clinical malaria episodes, OR 2.39 (95% CI 1.49; 3.86, p-value < 0.001, I2 = 0.0%, N = 3,053) for peripheral parasitaemia, and OR 1.88 (95% CI 1.06 to 3.33, p-value = 0.03, I2 = 34.9%, N = 3,847) for placental malaria. Among HIV-infected subgroups statistically significant associations were not observed. Similar associations were found in the subgroup analysis by gravidity. The small sample size and outcome prevalence in specific countries limited the inclusion of some countries in the meta-analysis. Furthermore, peripheral parasitaemia and placental malaria presented a considerable level of missing data-12.6% and 18.2% of participants had missing data on those outcomes, respectively. Given the original scope of the clinical trials, asymptomatic malaria infection was only assessed at the end of pregnancy through peripheral and placental parasitaemia.ConclusionsIn this study, we observed that adolescent girls in sub-Saharan Africa (SSA) are more prone to experience clinical malaria episodes during pregnancy and have peripheral malaria and placental infection at delivery than adult women. Moreover, to the best of our knowledge, for the first time this study disaggregates figures and stratifies analyses by HIV infection. Similar associations were found for both HIV-infected and uninfected women, although those for HIV-infected participants were not statistically significant. Our finding suggests that adolescent girls may benefit from targeted malaria prevention strategies even before they become pregnant.