Efficacy of Seasonal Intermittent Preventive Treatment With

EFFICACY OF SEASONAL INTERMITTENT PREVENTIVE TREATMENT WITH

SULPHADOXINE-PYRIMETHAMINE ON REDUCTION OF CLINICAL MALARIA

AND ANAEMIA IN UNDER FIVE CHILDREN PRESENTING IN SEVENTH-DAY

ADVENTIST HOSPITAL, JENGRE, PLATEAU STATE.

A DISSERTATION SUBMITTED TO NATIONAL POSTGRADUATE MEDICAL

COLLEGE OF NIGERIA (NPMCN) IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE AWARD OF FELLOWSHIP OF THE COLLEGE IN

FAMILY MEDICINE (FMCFM)

DR. EVEREST KEMAS (MBBS, UNIVERSITY OF JOS, 2006)

DEPARTMENT OF FAMILY MEDICINE,

JOS UNIVERSITY TEACHING HOSPITAL,

JOS, NIGERIA.

MAY 2016.

DECLARATION

I, Dr EVEREST KEMAS, hereby declare that this research work is original and that no part or whole work has been submitted to another examination body for Fellowship. Also that this work has not been submitted to any journal for publication.

______

DR. EVEREST KEMAS

DATE: ______

DEDICATION

This work is dedicated to GOD Almighty and to all under five children affected by malaria in

Nigeria and in Africa.

ACKNOWLEDGEMENT

I am eternally indebted to my supervisors Drs. Pitmang and Lar for painstakingly guiding me through this part of my training and investing their time and knowledge to make me what I am today.I am also grateful to Drs. Agaba and Isandu for reading through my script and for their most valued criticisms and encouragement that spurred me on.

To late Dr Dawam for providing me with materials that helped me in the course of writing this book.

To my entire family and friends, their support has been vital for me to accomplish this project.

To Mr Chris, the Laboratory technician for assisting me in analyzing my samples.

To Mr. Saint Pam for his assistance in the interpretation of the questionnaire in the local dialect to the respondents, as well as helping in data collection, I say a big thank you.

To my colleague Drs. Benjamin, Fatima Gyaran, Lamu, and others, I thank them for being there.

I also like to appreciate the efforts of Mr. Emmanuel, the statistician for analyzing my data.

Above all, I thank the Almighty God who had been my strength and for His faithfulness to me throughout the trying period of residency.

CERTIFICATION I

The study reported in this dissertation was carried out by Dr Everest Kemas under our supervision. We also supervised the writing of the dissertation.

SUPERVISORS:

1. Signature: ______Date: ______

DR. N LAR -NDAM (MBBS, FMCGP)

Consultant Family Physician

Department of Family Medicine, Jos University Teaching Hospital, Jos, Nigeria.

2. Signature: ______Date: ______

DR. S.L PIMANG (BMBCh, FMCGP)

Consultant Family Physician

Department of Family Medicine, Jos University Teaching Hospital, Jos, Nigeria.

(HEAD OF DEPARTMENT CERTIFICATION)

I certify that Dr. Everest Kemas of the Department of Family Medicine, Jos University Teaching Hospital, carried out this study under the supervision of Dr. Lar N.N, and Dr. Pitmang S.L.

______Date ______

Dr. AJK Madaki FWACP

Consultant and Head,

Department of Family Medicine,

Jos University Teaching Hospital, Jos.

TABLE OF CONTENT

Title Page ------i

Declaration ------ii

Dedication ------ii

Acknowledgement ------iii

Certification 1 ------iv

Table of Contents ------v

Chapters ------vi

List of Figures ------x

List of Tables ------xi

List of Abbreviations ------xii

Abstract ------1

CHAPTER ONE

1.0 Introduction ------3

1.1 Background ------3

1.2 Relevance of the Study to family Medicine Discipline - - - - 7

1.3 Statement of the Problem ------8

1.4 Study Hypothesis ------10

1.5 Justification of the Study ------10

1.6 Aims ------13

1.7 Objectives ------13

CHAPTER TWO

2.0 Literature Review ------14

2.1 Origin of Malaria ------14

2.2 History of Malaria ------14

2.3 Malaria Overview ------15

2.4 Mosquito Vector ------17

2.5 Epidemiology of Malaria ------17

2.5.1 Regional Epidemiology of Malaria in Nigeria - - - - - 19

2.6 Pathophysiology of Malaria ------20

2.6.1 Genetic Resistance ------22

2.6.2 Malarial Hepatopathy ------22

2.6.3 Recurrent Malaria ------24

2.7 Clinical Features of Malaria ------24

2.7.1 Uncomplicated Malaria ------25

2.7.2 Complicated/Severe Malaria ------27

2.8 Diagnosis of Malaria ------28

2.8.1 Clinical Diagnosis of Malaria ------29

2.8.2 Laboratory Diagnosis of Malaria ------30

2.8.3 Molecular Diagnostic Methods ------33

2.9 Treatment of Malaria ------33

2.9.1 Objectives of Treatment ------34

2.9.2 Treatment of Uncomplicated Malaria ------34

2.9.3 Treatment of Severe Malaria ------36

2.10 Malaria Prevention and Control ------40

2.10.1 Insecticides Treated Bed Nets ------40

2.10.2 Insecticide Spraying ------42

2.10.3 Vector Control ------43

2.10.4 Malaria Vaccine ------44

2.10.5 Malaria Chemoprophylaxis ------45

2.10.6 IPT (Intermittent Preventive Malaria Treatment) - - - - 46

2.10.7 Seasonal Malaria Chemoprevention ------48

CHAPTER THREE

3.0 Materials and Methods ------55

3.1 Study Area ------55

3.2 Period and Duration of Study ------55

3.3 Study Population ------55

3.4 Eligibility ------55

3.4.1 Inclusion Criteria ------55

3.4.2 Exclusion Criteria ------56

3.5 Study Hypothesis ------56

3.6 Study Design ------56

3.7 Sample Size Determination ------56

3.8 Ethical Consideration ------58

3.9 Study Procedure ------58

3.10 Recruitment and Allocation ------59

3.11 Definition of Terms ------60

3.12 Follow-up Procedure ------61

3.13 Control Group ------61

3.14 Drug Dosage and Schedule ------62

3.15 Method of Data Analysis ------62

3.16 Duration of Study ------62

3.17 Incentives ------62

CHAPTER FOUR

4.0 Results ------64

4.1 Socio-demographic Characteristics of Participants - - - - 66

4.2 Clinical History of Participants ------68

4.3 General Examination of Participants ------69

4.4 Effect of IPTc using S-P on Mean Axillary Temperature - - - 74

4.5 Effect of IPTc using S-P on Incidence of Clinical Malaria - - - 76

4.6 Effect of IPTc using S-P on Incidence of Anaemia - - - - 78

4.7 Effect of IPTc using S-P on Incidence of Severe Malaria - - - 83

CHAPTER FIVE

5.0 Discussion ------88

5.1 Strengths of Study ------95

5.2 Limitations of Study ------95

5.3 Implication of Study to Family Physicians and other Primary Care Physicians 96

5.4 Recommendations ------96

5.5 Conclusions ------97

References ------98

JUTH Ethical Clearance ------Appendix A

Consent Form ------Appendix B

Questionnaire ------Appendix C

LIST OF FIGURES

Figure 2.1 Life cycle of Malaria ------23

Figure 4.1 Flow chart of patient ------65

Figure 4.2 Mean and standard deviation of participant age - - - - 66

Figure 4.3 Overall mean axillary temperature of participants across follow up period 74

Figure 4.4 Kaplan meier curve for clinical malaria between study groups - - 78

Figure 4.5 Line trend for packed cell volume across study groups - - - 80

Figure 4.6 Line graph showing parasite density across study groups - - 84

LIST OF TABLES

Table 1: Socio-demographic characteristics of participants - - - 68

Table 2: History of study participants at baseline - - - - - 69

Table 3: Anthropometry of participants (Baseline) - - - - - 70

Table 4: Clinical parameters of participants at baseline - - - - 71

Table 5: Effect of IPTc using S-P on mean length of participants - - - 72

Table 6: Effect of IPTc using S-P on mean weight of participants - - - 73

Table 7: Effect of IPTc using S-p on mean head circumference of participants - 74

Table 8: Mean axillary temperature of participants - - - - - 75

Table 9: Effect of IPTc using S-P on the incidence of clinical malaria - - 77

Table 10: Test of Equality of time to event of clinical malaria for study groups - 78

Table 11: Mean packed cell volume of participants - - - - - 79

Table 12: Effect of IPTc using S-P on anaemia in participants - - - 81

Table 13: Incidence of Anaemia based on grading in study groups across follow up 82

Table 14: Mean parasite count of participants - - - - - 83

Table 15: Effect of IPTc using S-P on severe malaria across study groups - - 85

Table 16: Protective efficacy of malaria, anaemia and severe malaria - - 86

LIST OF ABBREVIATIONS

% Percentage

/ Per

< Less than

≤ Less than or equal to

= Equal to

> Greater than

≥ Greater than or equal to

0C Centigrade

Cm Centimeter

X2 Chi square

Kg Kilograms g Grams t Student ‘t’ test df Degree of freedom

ACT Artemisinin combination therapy.

AM Amodaquine

ARD Acute respiratory stress disorder

AS Artesunate

AQ Amodaquine

CI Confidence interval

DALY Daily adjusted life years

IPTc Intermittent Preventive Treatment in children

IPTi Intermitent Preventive Treatment in infants.

IRR Incidence rate ratio

IRS Indoor residual spraying

ITNs Insecticide treated nets

JUTH Jos university teaching hospital

LLIN Long lasting insecticide treated net p p-value

PCV Packed cell volume

PE Protective effect

PQ Piperaquine

SDA Seventh day Adventist hospital

SMC Seasonal malaria chemoprevention

SMP Sulphamethoxypyrazine- pyrimethamine

SP Sulphadoxine-pyrimethamine

UK United Kingdom

USA United State of America

WHO World Health Organization

Summary

Background

Malaria and anaemia are the leading causes of morbidity and mortality in children in sub-

Saharan Africa. Previous studies have shown that in areas of seasonal malaria transmission, intermittent preventive treatment of malaria in children (IPTc), targeting the transmission season, reduces the incidence of clinical malaria. However, these studies were conducted in other African countries. We have investigated the effect of intermittent preventive treatment with sulphadoxine-pyrimethamine on anaemia and malaria in children in an area of intense, prolonged, seasonal malaria transmission in Nigeria.

Methods

182 children aged 12–59 months from the study area were individually randomised to receive three doses of placebo or sulphadoxine-pyrimethamine (SP) monthly over a period of four months. The primary outcome measures were episodes of anaemia (Hb<10.0 g/dl), malaria or severe malaria detected through active and passive surveillance.

Results

Monthly sulphadoxine-pyrimethamine reduced the incidence of malaria and anaemia compared to placebo. The protective efficacy for malaria, severe malaria and Anaemia were

74%, 71% and 95% respectively. There were statistically significant reductions in the episodes of malaria, severe malaria and anaemia in the intervention group compared to the placebo group.

For clinical malaria; at 2nd visit 23.8% had malaria in the intervention group compared to

76.2% in the placebo group. (p- value 0.011). At 3rd visit 28.6% had malaria in the intervention group compared to 71.4% in the placebo group (p-value 0.014). At 4th visit

10.7% had malaria in the intervention group compared to 89.3% in the control group.(p-value

0.0005).

Kaplan Meier test was used to compare the time it takes for clinical malaria among participants in the study groups.The time of visit was measured in time intervals of 28 days in between visits. It showed that participants in the intervention group had significant lower probability of having clinical malaria than in the control group with in the earlier time of study.(Breslow test: 푥2=8.5573,df=1,p=0.003).

Tarone-Ware ( 푥2 =8.763,df=1,p=0.003) and Mantel Cox( 푥2 =8.825,df=1,p=0.003) test revealed that the control group have a higher probability of having clinical malaria than the intervention group in between the 2nd and 3rd visit and at the end of the time frame.

For Anaemia ; At 2nd visit 3.3% had anaemia in the intervention group compared to 13.2% in the control group.(p = 0.015). At 3rd visit 0.0% had anaemia in the intervention group compared to 14.3% in the control group. (p= 0.0005). At 4th visit 0.0% had anaemia in the intervention group compared to 34.1% in the control group.(p= 0.0005).

For Severe malaria; At 2nd visit 50% had severe malaria in both the intervention and control group.(p=1.000).At 3rd visit 33.3% and 66.7% had severe malaria in the intervention and control group respectively.(P=0.560).At 4th visit, none(0.0%) in the intervention group had severe malaria compared to four (100%) in the control group.(p=0.043).

Conclusion

IPTc is safe and efficacious in reducing the burden of malaria in an area of Nigeria with a prolonged, intense malaria transmission season.

CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND

The word malaria comes from 18th century Italian word mala meaning "bad" and aria meaning "air". Most likely, the term was first used by Dr. Francisco Torti, Italy, when people thought the disease was caused by foul air in marshy areas.1

It was not until 1880 that scientists discovered that malaria was a parasitic disease which is transmitted by the anopheles mosquito. The mosquito infects the host with a one-cell parasite called plasmodium. By the end of the 18th century, scientists found out that malaria was transmitted from person-to-person through the bite of the female mosquito, which needs Red blood cells for the production of her eggs.1

Malaria is caused by infection of red blood cells with protozoan parasites of the genus plasmodium. The parasites are inoculated into the human host by a feeding female anopheles mosquito. The four plasmodium species that infect humans are P. falciparum, P. ovale, P. vivax, and P. malariae. Increasingly, human infections with the monkey malaria parasite, P. knowlesi, have also been reported from the forested regions of the South-East Asia2.

Approximately 40% of the total global population is at risk of malaria infection. During the

20th century the disease was effectively eliminated in most of non-tropical countries.1

According to the World Health Organization1 (WHO):

 Approximately 660,000 people died from malaria in 2010 globally, most of them

were African children.

 There were an estimated 219 million cases of malaria infection in 2010 worldwide.

 Malaria is a preventable and curable disease.

 Malaria mortality rates have fallen by over 25% since 2000. In the WHO African

region rates have dropped by 33%.

 The malaria burden in many parts of the world is being dramatically reduced thanks to

increased malaria prevention and control measures.

 Travelers from malaria-free areas who enter endemic areas are especially vulnerable

to severe symptoms when they become infected.

 About 80% of all malaria cases occur in just 17 countries.

 Nigeria and the Democratic Republic of the Congo account for more than 40% of all

malaria deaths worldwide

Ninety per cent of malaria deaths occur in Africa, where malaria accounts for about one in six of all childhood deaths. The disease also contributes greatly to anaemia among children — a major cause of poor growth and development.3 Malaria is both preventable and treatable, and effective preventive and curative tools have been developed. Sleeping under Insecticide

Treated Nets (ITNs) can reduce overall child mortality by 20 per cent. There is evidence that

ITNs, when consistently and correctly used, can save six child lives per year for every one thousand children sleeping under them.3 Prompt access to effective treatment can further reduce deaths. Intermittent preventive treatment of malaria during pregnancy can significantly reduce the proportion of low birth weight infants and maternal anaemia.3

Unfortunately, many children, especially in Africa, continue to die from malaria as they do not sleep under insecticide-treated nets and are unable to access life-saving treatment within

24 hours of onset of symptoms. Due to the efforts of many partners and a focus on sustaining funding, from 2000 to 2010, the proportion of children sleeping under an ITN in sub-Saharan

Africa grew from 2 per cent to 39 percent.3

The burden of severe forms of Plasmodium falciparum malaria is concentrated in young children and a recent pooled analysis showed that this is even more pronounced for malaria leading to death than for less severe forms of the disease.4 The targeted provision of insecticide-treated nets to pregnant women5 and children under 5 years of age has helped protect those at an increased risk.6 Measures that target the very young may provide a useful additional strategy for malaria control.

Antimalarial drugs have been used in various ways to prevent malaria in the resident populations of endemic areas for nearly 100 years. The primary aim of most early studies was to interrupt transmission. Chemoprophylaxis is highly effective in reducing mortality and morbidity from malaria in young children and pregnant women living in endemic areas, but is difficult to sustain and, in some studies, has impaired the development of naturally acquired immunity.7

While our tools for controlling and eventually eliminating malaria are greater now than in days of the first malaria eradication effort, they are not limitless. Strides have been made in reducing the burden of malaria disease using insecticide treated nets (ITNs) for prevention and artemisinin based combination therapy (ACT) for treatment. Indoor residual spraying

(IRS), once the prime tool in the fight to eradicate the disease, is now used somewhat sparingly taking into consideration costs, logistics, and local epidemiological and ecological conditions. Vaccines are under development and new vector management technologies are being explored, but one other available strategy, intermittent preventive treatment (IPT) has not been deployed to its full potential.8

Intermittent preventive treatment (IPT) has been a mainstay for preventing malaria among pregnant women in countries with high and stable transmission of malaria for a dozen years.1The treatment dose of sulphadoxine-pyrimethamine (SP) is given after quickening during antenatal care (ANC) at monthly intervals to clear malaria parasites (particularly

Plasmodium falciparum) from the woman and her placenta in order to prevent anaemia, interuterine growth retardation (leading to low birth weight),9 still birth, neonatal death,10 and even maternal death.

As was reported in the May 2012 issue of Africa Health, extensive research had been done at multi-country sites to determine the efficacy and feasibility of implementing IPT for infants and children (IPTi and IPTc). The authors were concerned at the time that the results were not being put into practice to save children’s lives.8

Interestingly, IPTi and IPTc have undergone a slight transition and name change. In 2012, the

World Health Organization issued guidance on ‘Seasonal Malaria Chemoprevention (SMC) for Plasmodium falciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa.11 SMC is an adaptation of IPTi and IPTc for a specific geographical area where well-timed doses of anti-malarial drugs could play a major role in saving lives and reducing transmission. WHO explains that, ‘The word chemoprevention as used in SMC reported, means that areas meeting seasonality definition of 60% of annual incidence within four consecutive months were observed more frequently in the Sahel and sub-Sahel than in other parts of Africa, and thus provide an ideal focus for intervention.12 Malaria transmission in much of the Sahel is confined to less than four to five months of the year.13

From their data the Cairns group concluded that, a protective efficacy of 65% would be a reasonable estimate of protection provided by three courses over a 4-month peak.8 Four monthly courses over four months might provide protective efficacy of ~80%.’ They did caution that effective delivery of the intervention may pose challenges.8

Similarly Meremikwu et al 14conducted a Cochrane Review on IPTi studies relevant to

SMC.14 They concluded that, ‘in areas with seasonal malaria transmission, giving antimalarial drugs to preschool children (age <6 years) as IPTc during the malaria

21 transmission season markedly reduces episodes of clinical malaria, including severe malaria.

This benefit occurs even in areas where insecticide-treated net usage is high.’ As reflected in their finding, a multi-strategy approach that includes insecticide-treated nets is beneficial, especially in light of the implementation challenges of achieving three or four treatment contacts on a monthly basis.

As reported in Nature, pre-emptive treatment of children living in regions where [malaria] is prevalent only during the rainy season could avert 11 million cases of malaria and 50 000 deaths a year.15’ WHO explained that, ‘At test sites in Burkina Faso, bed nets have halved the number of malaria cases, and seasonal chemoprevention has reduced the remaining cases by about 80%.16 WHO noted that higher burden countries like the Democratic Republic of

Congo have year-round malaria transmission making the strategy more difficult and less effective than the focused approach possible with ‘just the right conditions’ in the Sahel.

The objective of IPTc is to maintain therapeutic anti-malarial drug concentrations in the blood throughout the period of greatest risk11. This will reduce the incidence of both simple and severe malaria disease and the associated anaemia and result in healthier, stronger children, able to develop and grow without interruption by disease episodes. SMC has been shown to be effective, cost effective and feasible for the prevention of malaria among children in areas where the malaria transmission season is no longer than four months11.

1.2 RELEVANCE OF THE STUDY TO FAMILY MEDICINE DISCIPLINE.

Family Medicine encourages the use of cost effective primary care and prevention strategies.

This is particularly relevant as malaria affects most families in Africa (especially the West

African region). The disease entity which is preventable (by tools such as, the use of ITNs and chemoprophylaxis e t c.) requires continuous, coordinated care offered mainly by

Primary care Physicians.

The information gained from the study will help to reduce the huge burden of mortality and morbidity due to malaria and thus, spare already scarce resources expended by the family and health care providers on malaria.

This study will generate important Public Health Information on the efficacy of IPTc in preventing clinical malaria and anaemia among children in an area with intense and prolonged malaria transmission season. This will compliment on-going prevention efforts like ITNs and Indoor Residual Spraying (IRS).

1.3 STATEMENT OF THE PROBLEM

Malaria has remained a major public health problem in Nigeria. It accounts for over 60% of out-patient visits and 30% of hospital admissions in Nigeria. The disease has impacted negatively on the economy with about 132 Billion Naira lost to the disease as cost of treatment and loss in man hours17.

Thirty countries in sub-Saharan Africa account for 90% of global malaria deaths. Nigeria,

Democratic Republic of Congo (DRC), Ethiopia and Uganda account for nearly 50% of the global malaria deaths. Malaria is the second leading cause of death from an infectious disease in Africa, after HIV/AIDS. Almost one out of five deaths in children under five years in

Africa are due to malaria.18

Malaria is a major public health problem in Nigeria where it accounts for more cases and deaths than in any other country in the world.18 Malaria is a risk for 97% of Nigeria’s population. The remaining 3% of the population live in the malaria free highlands. There are an estimated 100 million malaria cases with over 300,000 deaths attributable to malaria per year in Nigeria. This compares with 215,000 deaths per year in Nigeria from HIV/AIDS.18

Malaria has the greatest prevalence, close to 50%, in children age 6 – 59months in the South-

West, North Central and North West regions. Malaria has the least prevalence, 27.6 percent

23 in children aged 6 – 59 months on the South-East region18. Most malaria deaths occur among children living in Africa where a child dies every minute from malaria.

WHO country-level burden estimates available for 2010 showed that 80% of malaria deaths occurred in just 14 countries and about 80% of cases occurred in 17 countries. Together, the

Democratic Republic of Congo and Nigeria account for over 40% of the estimated malaria deaths globally. Children who survive malaria do not escape unharmed. Repeated episode of fever and anaemia take a toll on their mental and physical development, impairing their education and growth into productive adults. Pregnant women and their unborn children are also particularly vulnerable to malaria, even in areas of stable transmission, since malaria infection may lead to malaria-related anaemia in the mother and the presence of parasites in the placenta, which contributes to low birth weight.

Depending on various factors such as the parasite, the vector, the human host and the environment, the infected person will become ill with malaria after about a week to several months, but mostly within 17 – 21 days of malaria infection.

The two most powerful and most broadly applied interventions for malaria vector control and prevention are insecticide treated mosquito nets (ITNs) and indoors residual spraying (IRS).

However, malaria vector control with ITNs, IRS or other interventions is only effective with sustained high coverage. In 2010, WHO recommended the universal use of diagnostic testing to confirm malaria infection, followed by appropriate treatment based on the result.

According to the new guidelines, treatment solely on the basis of clinical suspicion should only be considered when a parasitological diagnosis is not accessible. Treatment should be with Artemisinin based Combination Therapy [ACT]19.

DEFINITION OF TERMS

Incidence – Is the frequency (number) of new occurrences of disease (Malaria). That is the number who becomes ill in the study population during the time of the study.

Seasonal Malaria Chemoprevention: Intermittent administration of full treatment courses of an antimalarial treatment combination during the malaria season to prevent illness and death from the disease.20

Uncomplicated Clinical Malaria: defined as symptomatic malaria without signs of severity or evidence [clinical or laboratory] of vital organ dysfunction. The signs and symptoms of uncomplicated malaria are non-specific. Malaria is therefore suspected clinically mostly on the basis of fever or a history of fever.21

Severe Falciparum malaria: Acute falciparum malaria with signs of severity and/or evidence of vital organ dysfunction. The presence of one or more of the clinical or

Laboratory features classifies the person as suffering from severe malaria.21

Clinical Anaemia: A haemoglobin level of less than 10g per deciliter (Packed Cell Volume

Less Than 30% Percent) or presence of signs (Pallor, shortness of breath, tachypnoea) in children in this age group.22

1.4 STUDY HYPOTHESIS

The study hypothesis is that monthly therapeutic doses of S-P administered over the course of

3 months to children under the age of five during the season of high malaria transmission will

Improve haematocrit and reduce the incidence of clinical malaria.

1.5 JUSTIFICATION OF THE STUDY

The burden of malaria is quite high. It is responsible for 300-500 million clinical cases per year, 80% of these occur in Africa. It is responsible for 1 million deaths per year, all virtually

25 due to plasmodium falciparum; with 90% of these occuring in Africa.17Malaria impedes human development and is both a cause and consequence of under development. Every year, malaria is said to cost Africa an estimated $12 billion in lost productivity. Nigeria loses over

N133 billion from the cost of treatment and absenteeism from work, schools and farm to the cost effective drugs and insecticides17.

Other effects of malaria could be seen in the following areas.

 Technology – In research and development (RRD) due to increasing drug resistance

to hitherto cost effective drugs and insecticides.

 Socials – The nuisance of mosquitoes with the noise and sleep disturbance.

 International co-operation: malaria ties negative effects on tourism and travels

especially during the high transmission seasons.

 The roll back malaria (RBM) strategies and goals are far from being reached. A

malaria situation analysis carried out by the FMOH (Federal Ministry of Health) in

the Year 2000 revealed the following findings:

 The perception of the cause of malaria is poor and very few people link mosquito to

malaria.

 80% of malaria cases are inadequately managed at community level by the facility

and home based caregivers.

 Only 5% of antimalaria drugs are produced in Nigeria.

 85% of health facilities surveyed in rural areas had stock out. None had prepackaged

drugs.

 51% of mothers obtain drugs from patent medicine vendors, 89% of the drugs were

found to be sub-standard and 43% of syrups unsatisfactory.

WHO estimated that in 2010, there were 219 million cases of malaria (with an uncertainty range of 154 million to 289 million) leading to approximately 660,000 deaths (with an uncertainty range of 610,000 to 971,000), mostly among African children. Most death occurs among children living in Africa where a child dies every minute from malaria. Between 2000 and 2010 malaria mortality rates fell by more than 25% globally. Although those reductions constitute major achievements in the global fight against malaria, these rates of decline are lower than global targets for 2010.19

Children who survive malaria may not escape unharmed. Repeated episodes of fever and anaemia take a toll on their mental and physical development, impairing their education and their growth into productive adults. Pregnant women and their unborn children are also particularly vulnerable to malaria, even in areas of stable transmission, since malaria infection may lead to malaria related anaemia in the mother. The presence of parasite in the placenta, which contributes to low birth weight is a leading cause of impaired development and infant mortality19.

A study conducted by A l Zoakah et al23 on the prevalence and outcome of malaria amongst under five children at comprehensive health centre, Gindiri revealed that malaria was still the commonest cause of morbidity and mortality amongst under-fives especially in children less than one year in north central Nigeria23.

A study carried out by J C Daboer et al24, on malaria parasitaemia and household use of insecticide treated bed nets; a cross-sectional survey of under-fives in Jos, Nigeria revealed that malaria parasitaemia was high in that community and sleeping under insecticide treated bed nets has been found to significantly reduce the prevalence of parasitaemia in the children studied. With parasitaemia prevalence of 38%, malaria was still a major public health problem among under-five in the study environment24. Amongst communities, malaria remained a leading health concern.25

Countries in regions of stable and intense malaria transmission have adopted a policy of IPT for pregnant women (IPTp) using the drug sulphadoxine-pyrimethamine (SP) twice during the pregnancy after quickening. SP has a one-dose malaria regimen and thus is ideal for administration as directly observed treatment (DOT) during antenatal care (ANC) visits. The benefits of IPTp and IPTi have been demonstrated by several researchers and are currently being promoted by WHO for women and infants living in endemic areas. Studies conducted in most African countries have also demonstrated the beneficial effect of IPTc (intermittent preventive treatment in children) especially during the season of high malaria transmission

(August to October).8 Studies on both IPTi and IPTc are lacking in Nigeria, which together with Democratic Republic of Congo account for over 40% of the estimated total malaria deaths globally.8

This study seeks, therefore, to administer monthly therapeutic doses of Sulphadoxine- pyrimethamine as seasonal malaria chemoprevention to children less than five years to determine if it would be efficacious and protective against clinical malaria and anaemia in under-fives.

1.6 AIM

To investigate the effect of Seasonal Intermittent Preventive Treatment using S-P on the incidence of clinical malaria and anaemia in children between 1-5years in the under-five clinic at the Seventh-Day Adventist Hospital, Jengre, Plateau State so as to formulate a treatment protocol to be adopted in my centre.

1.7 OBJECTIVES

1) To determine the short term effect of S-P as seasonal intermittent preventive

treatment on the incidence of clinical malaria in children less than five years of

age.

2) To determine the effect of S-P as seasonal intermittent preventive treatment on

anaemia in children under-five years.

3) To find out the effect of S-P as seasonal intermittent preventive treatment on the

incidence of severe malaria in children under-five years of age.

CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 ORIGIN OF MALARIA

Human malaria likely originated in Africa and has coevolved along with its hosts, mosquitoes and non-human primates. The first evidence of malaria parasites was found in mosquitoes preserved in amber from the Palaeogene period that are approximately 30 million years old.26

Malaria may have been a human pathogen for the entire history of the species.27,28 Humans may have originally caught Plasmodium falciparum from gorillas.29 About 10,000 years ago malaria started having a major impact on human survival which coincides with the start of agriculture (Neolithic revolution); a consequence was natural selection for sickle-cell disease, thalassaemias, glucose-6-phosphate dehydrogenase deficiency, ovalocytosis, elliptocytosis and loss of the Gerbich antigen (glycophorin C) and the Duffy antigen on the erythrocytes because such blood disorders confer a selective advantage against malaria infection

(balancing selection).30 The three major types of inherited genetic resistance (sickle-cell disease, thalassaemias, and glucose-6-phosphate dehydrogenase deficiency) were present in the Mediterranean world by the time of the Roman Empire, about 2000 years ago.31

2.2 HISTORY OF MALARIA

References to the unique periodic fevers of malaria are found throughout recorded history.32

According to legend, the Chinese emperor Huang Di (Yellow Emperor, 2697–2590 BCE) ordered the compilation of a canon of internal medicine. The Chinese Huangdi Neijing (The

Inner Canon of the Yellow Emperor) apparently refers to repeated paroxysmal fevers associated with enlarged spleens and a tendency to epidemic occurrence – the earliest written report of malaria.33 The presence of malaria in Egypt from circa 800 BC onwards has been confirmed using DNA based methologies.34 The term 'miasma' was coined by Hippocrates of

Kos who used it to describe dangerous fumes from the ground that are transported by winds

30 and can cause serious illnesses. The name malaria was derived from ‘mal’aria’ (bad air in

Medieval Italian). This idea came from the Ancient Romans who thought that this disease came from the horrible fumes from the swamps. The word malaria has its roots in the miasma theory, as described by historian and chancellor of Florence Leonardo Bruni in his Historia

Florentina, which was the first major example of Renaissance historical writing:35

The Italian investigators Giovanni Batista Grassi and Raimondo Filetti first introduced the names Plasmodium vivax and P. malariae for two of the malaria parasites that affect humans in 1890. Laveran had believed that there was only one species, Oscillaria malariae. An

American, William H. Welch, reviewed the subject and, in 1897, he named the malignant tertian malaria parasite P. falciparum. There were many arguments against the use of this name; however, the use was so extensive in the literature that a change back to the name given by Laveran was no longer thought possible. In 1922, John William Watson Stephens described the fourth human malaria parasite, P. ovale. P. knowlesi was first described by

Robert Knowles and Biraj Mohan Das Gupta in 1931 in a long-tailed macaque. The first documented human infection with P. knowlesi was in 1965.36

2.3 MALARIA OVERVIEW

Malaria occurs in nearly 100 countries worldwide, exacting a huge toll on human health and imposing a heavy social and economic burden in developing countries, particularly in Sub-

Saharan Africa and South Asia. More than 200 million people suffered from the disease in

2010, and about 655,000 died, the vast majority of them children under age five.37

Malaria is caused by parasites that are spread by mosquitoes, and even in relatively mild cases it can cause high fever, chills, flu-like symptoms, and anemia, which can be especially dangerous for pregnant women. Children who survive severe malaria can suffer lifelong

31 mental disabilities. Malaria’s economic impact is estimated to cost billions of dollars in lost productivity every year.37

Malaria is preventable and treatable, and history shows that it can be eliminated. Less than a century ago, it was prevalent across the world, including Europe and North America. In high- income countries, aggressive prevention measures and more effective monitoring and treatment gradually brought the disease under control and then led to elimination—which the

World Health Organization defines as the complete interruption of mosquito transmission of the disease for three or more years. In the United States, this milestone was achieved in

1951.37

Major gains have been made in controlling malaria in developing nations. In the past decade, malaria incidence has fallen by at least 50 percent in one-third of the countries where the disease is endemic. These gains have been made through a combination of interventions, including timely diagnosis and treatment using reliable tests and anti-malarial drugs; indoor spraying with safe insecticides; and the use of long-lasting, insecticide-treated bed nets to protect people from mosquito bites at night.37

However, current tools and treatments are insufficient to achieve elimination in many countries, let alone global eradication. In the meantime, malaria could rebound quickly as the parasites develop resistance to currently available insecticides and treatments. Both forms of resistance have already emerged as serious potential threats to effective and affordable malaria control.37

Innovation is essential to meeting these challenges and maintaining progress against malaria.

Sustained research and development (R&D) is needed to create a diverse array of treatment and prevention tools and thus avoid overreliance on a small set of anti-malaria tools, which has proven risky for effective malaria control.37

Fortunately, global commitment to fighting malaria has solidified; malaria funding has increased almost six-fold since 2003. Through the Global Malaria Action Plan, the World

Health Organization (WHO) and the Roll Back Malaria Partnership are coordinating international efforts. But we still need more effective policies and increased funding to secure lasting gains against one of humanity’s greatest health threats.37

2.4 MOSQUITO VECTOR

The mosquito has been described as the most dangerous animal in the world and the mosquito-borne disease with the greatest detrimental impact is undoubtedly malaria.

There are about 3,500 mosquito species and those that transmit malaria all belong to a sub-set called the Anopheles. Approximately 40 Anopheles species are able to transmit malaria well enough to cause significant human illness and death.

The information that tells us whether a mosquito species is likely to be an effective carrier

(vector) of the malaria parasite is its bionomics.38 Mosquitoes choose the blood donor by odours and visual clues and can learn from experience! Human behaviour also plays a role and males are more frequently bitten.39

The genome of A. gambiae has now been cracked and the effort is expected to help in future research into mosquito control strategies.39 Apart from malaria, anopheles mosquitoes are also known to transmit W. bancrofti (filarial worm); the Timorese filaria, Brugia timori; several arboviruses including eastern and western equine encephalitis, Venezualan equine encephalitis, onyong-nyong, tataguine etc.

2.5 EPIDEMIOLOGY OF MALARIA

Based on documented cases, the WHO estimates that there were 219 million cases of malaria in 2010 resulting in 660,000 deaths.40 This is equivalent to roughly 2000 deaths every day.41

A 2012 study estimated number of documented and undocumented deaths in 2010 was

1.24 million. The majority of cases (65%) occur in children under five years old.42,43

Pregnant women are also especially vulnerable: about 125 million pregnant women are at risk of infection each year. In Sub-Saharan Africa, maternal malaria is associated with up to

200,000 estimated infant deaths yearly.44 There are about 10,000 malaria cases per year in

Western Europe, and 1300–1500 in the United States.45 About 900 people died from the disease in Europe between 1993 and 2003.46 Both the global incidence of disease and resulting mortality have declined in recent years. According to the WHO, deaths attributable to malaria in 2010 were reduced by over a third from a 2000 estimate of 985,000, largely due to the widespread use of insecticide-treated nets and artemisinin-based combination therapies.47

Malaria is presently endemic in a broad band around the equator, in areas of the Americas, many parts of Asia, and much of Africa; however, it is in Sub-Saharan Africa where 85–90% of malaria fatalities occur.48 According to world malaria report 2010, the global prevalence of the disease was estimated at 225 million cases and 781000 deaths in 2009 49 .An estimate for

2010 said the deadliest countries per population were Burkina Faso, Mozambique and Mali.43

The Malaria Atlas Project aims to map global endemic levels of malaria, providing a means with which to determine the global spatial limits of the disease and to assess disease burden.50,51 This effort led to the publication of a map of P. falciparum endemicity in 2010.52

As of 2010, about 100 countries have endemic malaria.40,53 Every year, 125 million international travellers visit these countries, and more than 30,000 contract the disease.46

The geographic distribution of malaria within large regions is complex, and malaria-afflicted and malaria-free areas are often found close to each other.54 Malaria is prevalent in tropical and subtropical regions because of rainfall, consistent high temperatures and high humidity, along with stagnant waters in which mosquito larvae readily mature, providing them with the

34 environment they need for continuous breeding.55 In drier areas, outbreaks of malaria have been predicted with reasonable accuracy by mapping rainfall.56 Malaria is more common in rural areas than in cities. For example, several cities in the Greater Mekong Sub-region of

Southeast Asia are essentially malaria-free, but the disease is prevalent in many rural regions, including along international borders and forest fringes.57 In contrast, malaria in Africa is present in both rural and urban areas, though the risk is lower in the larger cities.58

2.5.1 Regional Epidemiology of Malaria in Nigeria

Nigeria is made up of six geopolitical zones and 36 states including the Federal Capital

Territory.7 Nigeria have a tropical climate with wet and dry seasons. The dry season occurs from October to March and the wet season between April and September. There is a period of cooler weather accompanied by the dry, dusty Harmattan wind, felt mostly in the north in

December and January. The temperature in Nigeria varies between 25°C and 40°C, and rainfall ranges from 2,650 millimetres in the southeast to less than 600 millimetres in some parts of the north, mainly on the fringes of the Sahara Desert.7 The ecology of Nigeria varies from the mangrove swamps and tropical rain forest belts in the coastal areas through to open woodland and savannah on the low plateau, which extends through much of the central part of the country to the semi-arid plains and Sahel grassland in the north and the highlands to the east. The geographic location of Nigeria makes the climate suitable for malaria transmission throughout the country. The seasonality, intensity and duration of the malaria transmission season vary according to the five ecological strata that extend from the south to the north. These include mangrove swamps, rain forest, guinea-savannah, sudan-savannah, and sahel-savannah.

The duration of malaria transmission is longer in the south and reduces as one moves north, being perennial in duration in most of the south, but lasting three months or less in the northeast region bordering Chad7.

The dominant vector species in Nigeria are the Anopheles gambiae species and the A. funestus group. The most prevalent species of malaria parasites in Nigeria is Plasmodium falciparum (over 95 percent). It is responsible for the most severe forms of the disease. The other types found in the country, Plasmodium ovale and Plasmodium malariae, play a minor role. Plasmodium malariae tends to only occur in children with mixed infections.7

Most lethal infections are due to Plasmodium falciparum. The disease causes symptoms such as fever, shivers, headache and muscular pain, anaemia and splenomegaly. Involvement of the brain often leads to death. For some years P. falciparum has been developing increasing resistance to chloroquine and other anti-malaria products. This, of course, makes treatment difficult. Many mosquitoes which are responsible for transmission of the disease are becoming resistant to a number of insecticides and this makes vector control difficult.

P. falciparum is the most common form in sub-Saharan Africa. It occurs chiefly in Africa, tropical South America and Southeast Asia. The parasite occurred previously in the

Mediterranean basin.

P. Vivax has the widest distribution area (previously as far as London, Norway, Denmark,

New York, southern Canada and even Siberia). Duffy blood group negative erythrocytes are, in vitro, also resistant to infection with P. knowlesi (monkey malaria). In 2011, it was reported that P. vivax could be found in Duffy negative individuals. This finding suggests the idea that this parasite is able to use receptors other than Duffy to invade erythrocytes.

P. ovale is found chiefly West Africa, less elsewhere in Africa and sporadically in the Far

East. P. ovale wallikeri and P. ovale curtesii seem to be sympatric, but more study is needed.

P. malariae is not very common anywhere. Often, it is confused with P. knowlesi.

P. knowlesi is known from Malaysia (including Borneo), The Philippines, Singapore and

Thailand. The vector is present in India (Kerala) and Sri Lanka, but in these areas there is no known zoonotic reservoir. Often confused with P. malariae.59

2.6 PATHOPHYSIOLOGY OF MALARIA

Malaria infection develops in two phases: one that involves the liver (exoerythrocytic phase), and one that involves red blood cells, or erythrocytes (erythrocytic phase). When an infected mosquito pierces a person's skin to take a blood meal, sporozoites in the mosquito's saliva enter the bloodstream and migrate to the liver where they infect hepatocytes, multiplying asexually and asymptomatically for a period of 8–30 days.60

After a potential dormant period in the liver, the parasites differentiate to yield thousands of merozoites, which, following rupture of their host cells, escape into the blood and infect red blood cells to begin the erythrocytic stage of the life cycle.60 The parasite escapes from the liver undetected by wrapping itself in the cell membrane of the infected host liver cell.61

Within the red blood cells, the parasites multiply further, again asexually, periodically breaking out of their host cells to invade fresh red blood cells. Several such amplification cycles occur. Thus, classical descriptions of waves of fever arise from simultaneous waves of merozoites escaping and infecting red blood cells.60

Some P. vivax sporozoites do not immediately develop into exoerythrocytic-phase merozoites, but instead produce hypnozoites that remain dormant for periods ranging from several months (7–10 months is typical) to several years. After a period of dormancy, they reactivate and produce merozoites. Hypnozoites are responsible for long incubation and late relapses in P. vivax infections,62 although their existence in P. ovale is uncertain.63

The parasite is relatively protected from attack by the body's immune system because for most of its human life cycle it resides within the liver and blood cells and is relatively invisible to immune surveillance. However, circulating infected blood cells are destroyed in the spleen. To avoid this fate, the P. falciparum parasite displays adhesive proteins on the surface of the infected blood cells, causing the blood cells to stick to the walls of small blood vessels, thereby sequestering the parasite from passage through the general circulation and the spleen.64 The blockage of the microvasculature causes symptoms such as in placental malaria.65 Sequestered red blood cells can breach the blood–brain barrier and cause cerebral malaria.66

Although the red blood cell surface adhesive proteins (called PfEMP1, for P. falciparum erythrocyte membrane protein 1) are exposed to the immune system, they do not serve as good immune targets because of their extreme diversity; there are at least 60 variations of the protein within a single parasite and even more variants within whole parasite populations.

The parasite switches through a broad repertoire of PfEMP1 surface proteins, thereby avoiding detection by protective antibodies.67

2.6.1Genetic Resistance

Due to the high levels of mortality and morbidity caused by malaria especially the

P. falciparum species, it has placed the greatest selective pressure on the human genome in recent history. Several genetic factors provide some resistance to it including sickle cell trait, thalassaemia traits, glucose-6-phosphate dehydrogenase deficiency, and the absence of Duffy antigens on red blood cells.68,69

The impact of sickle cell trait on malaria immunity is of particular interest. Sickle cell trait causes a defect in the hemoglobin molecule in the blood. Instead of retaining the biconcave shape of a normal red blood cell, the modified hemoglobin S molecule causes the cell to

38 sickle or distort into a curved shape. Due to the sickle shape, the molecule is not as effective in taking or releasing oxygen. Infection causes red cells to sickle more, and so they are removed from circulation sooner. This reduces the frequency with which malaria parasites complete their life cycle in the cell. Individuals who are homozygous (with two copies of the abnormal hemoglobin beta allele) have sickle-cell anaemia, while those who are heterozygous (with one abnormal allele and one normal allele) experience resistance to malaria. Although the shorter life expectancy for those with the homozygous condition seems to be unfavourable to the trait's survival, the trait is preserved because of the benefits provided by the heterozygous form.69,70

2.6.2 Malarial Hepatopathy

Liver dysfunction as a result of malaria is rare and is usually a result of a coexisting liver condition such as viral hepatitis or chronic liver disease. The syndrome is sometimes called malarial hepatitis, although inflammation of the liver (hepatitis) does not actually occur.

While traditionally considered a rare occurrence, malarial hepatopathy has seen an increase, particularly in Southeast Asia and India. Liver compromise in people with malaria correlates with a greater likelihood of complications and death.71

Figure 2.1:The life cycle of malaria parasites:

A mosquito causes infection by taking a blood meal. First, sporozoites enter the bloodstream, and migrate to the liver. They infect liver cells, where they multiply into merozoites, rupture the liver cells, and return to the bloodstream. Then, the merozoites infect red blood cells, where they develop into ring forms, trophozoites and schizonts that in turn produce further merozoites. Sexual forms are also produced, which, if taken up by a mosquito, will infect the insect and continue the life cycle.

In the life cycle of Plasmodium, a female Anopheles mosquito (the definitive host) transmits a motile infective form (called the sporozoite) to a vertebrate host such as a human (the secondary host), thus acting as a transmission vector. A sporozoite travels through the blood vessels to liver cells (hepatocytes), where it reproduces asexually (tissue schizogony), producing thousands of merozoites. These infect new red blood cells and initiate a series of asexual multiplication cycles (blood schizogony) that produce 8 to 24 new infective merozoites, at which point the cells burst and the infective cycle begins anew.72

Other merozoites develop into immature gametocytes, which are the precursors of male and female gametes. When a fertilised mosquito bites an infected person, gametocytes are taken

40 up with the blood and mature in the mosquito gut. The male and female gametocytes fuse and form a ookinete ,a fertilized, motile zygote. Ookinetes develop into new sporozoites that migrate to the insect's salivary glands, ready to infect a new vertebrate host. The sporozoites are injected into the skin, in the saliva, when the mosquito takes a subsequent blood meal.73

Only female mosquitoes feed on blood; male mosquitoes feed on plant nectar, and thus do not transmit the disease. The females of the Anopheles genus of mosquito prefer to feed at night.

They usually start searching for a meal at dusk, and will continue throughout the night until taking a meal.74 Malaria parasites can also be transmitted by blood transfusions, although this is rare.75

2.6.3 Recurrent malaria

Symptoms of malaria can recur after varying symptom-free periods. Depending upon the cause, recurrence can be classified as either recrudescence, relapse, or re-infection.

Recrudescence is when symptoms return after a symptom-free period. It is caused by parasites surviving in the blood as a result of inadequate or ineffective treatment.2 Relapse is when symptoms reappear after the parasites have been eliminated from blood but persist as dormant hypnozoites in liver cells. Relapse commonly occurs between 8–24 weeks and is commonly seen with P. vivax and P. ovale infections.41 P. vivax malaria cases in temperate areas often involve overwintering by hypnozoites, with relapses beginning the year after the mosquito bite.62 Reinfection means the parasite that caused the past infection was eliminated from the body but a new parasite was introduced. Reinfection cannot readily be distinguished from recrudescence, although recurrence of infection within two weeks of treatment for the initial infection is typically attributed to treatment failure.2

2.7 CLINICAL FEATURES OF MALARIA

Infection with malaria parasites may result in a wide variety of symptoms, ranging from absent or very mild symptoms to severe disease and even death. Malaria disease can be categorized as uncomplicated or severe (complicated).76 In general, malaria is a curable disease if diagnosed and treated promptly and correctly.

All the clinical symptoms associated with malaria are caused by the asexual erythrocytic or blood stage parasites. When the parasite develops in the erythrocyte, numerous known and unknown waste substances such as hemozoin pigment and other toxic factors accumulate in the infected red blood cell. These are dumped into the bloodstream when the infected cells lyse and release invasive merozoites. The hemozoin and other toxic factors such as glucose phosphate isomerase (GPI) stimulate macrophages and other cells to produce cytokines and other soluble factors which act to produce fever and rigors and probably influence other severe pathophysiology associated with malaria.76

Plasmodium falciparum-infected erythrocytes, particularly those with mature trophozoites, adhere to the vascular endothelium of venular blood vessel walls and do not freely circulate in the blood. When this sequestration of infected erythrocytes occurs in the vessels of the brain it is believed to be a factor in causing the severe disease syndrome known as cerebral malaria, which is associated with high mortality.76Following the infective bite by the

Anopheles mosquito, a period of time (the "incubation period") goes by before the first symptoms appear. The incubation period in most cases varies from 7 to 30 days. The shorter periods are observed most frequently with P. falciparum and the longer ones with P. malariae.76

2.7.1 Uncomplicated Malaria

The classical (but rarely observed) malaria attack lasts 6-10 hours. It consists of a cold stage

(sensation of cold, shivering), a hot stage (fever, headaches, vomiting; seizures in young children), and finally a sweating stage (sweats, return to normal temperature, tiredness).76

These occur every two days (tertian fever) in P. vivax and P. ovale infections, and every three days (quartan fever) for P. malariae. P. falciparum infection can cause recurrent fever every

36–48 hours or a less pronounced and almost continuous fever.77

The signs and symptoms of malaria typically begin 8–25 days following infection;78 however, symptoms may occur later in those who have taken antimalarial medications as prevention.79 Initial manifestations of the disease common to all malaria species are similar to flu-like symptoms80 and can resemble other conditions such as septiceamia, gastroenteritis, and viral diseases.79 The presentation may include headache, fever, shivering, joint pain, vomiting, hemolytic anemia, jaundice, hemoglobin in the urine, retinal damage, and convulsions.81

In countries where cases of malaria are infrequent, these symptoms may be attributed to influenza, a cold, or other common infections, especially if malaria is not suspected.

Conversely, in countries where malaria is frequent, residents often recognize the symptoms as malaria and treat themselves without seeking diagnostic confirmation ("presumptive treatment").76

Physical findings may include: Elevated temperatures, Perspiration, Weakness Enlarged spleen, Mild jaundice, Enlargement of the live, increased respiratory rate76

Severe malaria is usually caused by P. falciparum (often referred to as falciparum malaria).

Symptoms of falciparum malaria arise 9–30 days after infection.80 Individuals with cerebral malaria frequently exhibit neurological symptoms, including abnormal posturing, nystagmus,

43 conjugate gaze palsy (failure of the eyes to turn together in the same direction), opisthotonus, seizures, or coma.80

The World Health Organization (WHO) has defined criteria for recognizing severe falciparum malaria.

2.7.2 Complicated/Severe Malaria

Severe falciparum malaria is defined as; one or more of the defining criteria below

Asexual parasitemia with Plasmodium falciparum (although smear-negative cerebral malaria may occur)82

Defining Criteria Finding Cerebral malaria (unrousable unrousable coma not attributable to any other cause in a patient coma) with falciparum malaria. Coma should persist at least 30 minutes after a generalized convulsion to make the distinction from transient post-ictal coma. Severe normocytic anemia normocytic anemia with hematocrit <15% or hemoglobin <5 g/dL in the presence of parasitemia >10,000 parasites per µL. If microcytic indices seen, need to consider iron deficiency anemia, thalassemia and hemoglobinopathy. Renal failure urine output <400 mL in 24 hours in adults, or 12 mL per kg in children, failing to improve after rehydration, and with serum creatinine >265 µmol/L (3 mg/dL) Pulmonary edema, ARDS Fluid accumulation in the alveoli of the lungs resulting in severe shortness of breath, low blood pressure, confusion and extreme tiredness. Hypoglycemia whole blood glucose <2.2 mmol/L (<40 mg/dL) Circulatory collapse, shock hypotension (systolic blood pressure <50 mm Hg in children 1-5 years old; <70 mm Hg in adults) with cold, clammy skin or a core-to-skin temperature difference >10°C Spontaneous bleeding. DIC spontaneous bleeding from gums, nose, GI tract or other sites, with laboratory evidence of DIC Repeated generalized seizures more than 2 observed seizures (>=3) within 24 hours despite cooling Acidemia or acidosis arterial pH <7.25, plasma bicarbonate <15 mmol/L Malarial hemoglobinuria need to exclude hemoglobinuria due to antimalarial medications and to G6PD deficiency Additional Criteria Finding Impaired consciousness but impaired consciousness less marked than unrousable coma, can rousable localize a painful stimulus Prostration and extreme weakness patient unable to sit or walk, with no other obvious neurological explanation Hyperparasitemia very high parasite densities are associated with increased risk of severe disease but is affected by the immune status (more than 5% parasitemia in non-immune is serious, but may be well tolerated in semi-immune children); >500,000 per µL Jaundice total bilirubin >50 µmol/L (>3 mg/dL) Hyperpyrexia rectal temperature >40°C Post-mortem evidence of severe neuropathologic evidence of venules and capillaries packed with malaria erythrocytes containing malarial parasites

Risk factors for development of severe falciparum malaria include splenectomy , pregnancy, especially primigravida , immunosuppression and low immunity states: non-immune (lack of previous exposure), especially in small children, or lapsed immunity (due to living away from malarious area for several years) 82

2.8 DIAGNOSIS OF MALARIA

Prompt and accurate diagnosis is critical to the effective management of malaria. The global impact of malaria has spurred interest in developing effective diagnostic strategies not only for resource-limited areas where malaria is a substantial burden on society, but also in developed countries, where malaria diagnostic expertise is often lacking 83,84. Malaria diagnosis involves identifying malaria parasites or antigens/products in patient blood.

Although this may seem simple, the diagnostic efficacy is subject to many factors. The different forms of the five malaria species; the different stages of erythrocytic schizogony, the endemicity of different species, the interrelation between levels of transmission, population movement, parasitemia, immunity, and signs and symptoms; drug resistance, the problems of recurrent malaria, persisting viable or non-viable parasitemia, and sequestration of the parasites in the deeper tissues, and the use of chemoprophylaxis or even presumptive treatment on the basis of clinical diagnosis, can all influence the identification and interpretation of malaria parasitemia in a diagnostic test.

Malaria is a potential medical emergency and should be treated accordingly. Delays in diagnosis and treatment are leading causes of death in many countries85. Characteristics of a useful malaria diagnostic tool include the ability to definitively establish presence or absence of infection, determine which species of malaria is/are present, quantify parasitemia (ie, parasites per microliter of blood, or percent red blood cells infected), detect low-level parasitemia, and allow monitoring of response to antimalarial therapy (including detection of recrudescence or relapse). Thus far, there is no single malaria diagnostic tool that meets all of

46 these criteria. Test characteristics that are important for diagnosis vary depending on the epidemiology of infection and goals for control in the region where the test is used.86

2.8.1 Clinical Diagnosis of Malaria

A clinical diagnosis of malaria is traditional among medical doctors. This method is least expensive and most widely practiced. Clinical diagnosis is based on the patients' signs and symptoms, and on physical findings at examination. The earliest symptoms of malaria are very nonspecific and variable, and include fever, headache, weakness, myalgia, chills, dizziness, abdominal pain, diarrhea, nausea, vomiting, anorexia, and pruritus 87. A clinical diagnosis of malaria is still challenging because of the non-specific nature of the signs and symptoms, which overlap considerably with other common, as well as potentially life- threatening diseases, e.g. common viral or bacterial infections, and other febrile illnesses. The overlapping of malaria symptoms with other tropical diseases impairs diagnostic specificity, which can promote the indiscriminate use of antimalarials and compromise the quality of care for patients with non-malarial fevers in endemic area88-90. The Integrated Management of

Children Illness (IMCI) has provided clinical algorithms for managing and diagnosing common childhood illnesses by minimally trained healthcare providers in the developing world having inappropriate equipment for laboratory diagnosis. A widely utilized clinical algorithm for malaria diagnosis, compared with a fully trained pediatrician with access to laboratory support, showed very low specificity (0-9%) but 100% sensitivity in African settings91,92 . This lack of specificity reveals the perils of distinguishing malaria from other causes of fever in children on clinical grounds alone. Recently, another study showed that use of the IMCI clinical algorithm resulted in 30% over-diagnosis of malaria93. Therefore, the accuracy of malaria diagnosis can be greatly enhanced by combining clinical-and parasite- based findings.94

2.8.2 Laboratory Diagnosis of Malaria

Rapid and effective malaria diagnosis not only alleviates suffering, but also decreases community transmission. The nonspecific nature of the clinical signs and symptoms of malaria may result in over-treatment of malaria or non-treatment of other diseases in malaria- endemic areas, and misdiagnosis in non-endemic areas95. In the laboratory, malaria is diagnosed using different techniques, e.g. conventional microscopic diagnosis by staining thin and thick peripheral blood smears96, other concentration techniques, e.g. quantitative buffy coat (QBC) method95, rapid diagnostic tests e.g., OptiMAL97,98, ICT99, Para-HIT-f 90,

ParaScreen100, SD Bioline 101, Paracheck102, and molecular diagnostic methods, such as polymerase chain reaction (PCR)103,104. Some advantages and shortcomings of these methods have also been described, related to sensitivity, specificity, accuracy, precision, time consumed, cost-effectiveness, labour intensiveness, the need for skilled microscopists, and the problem of inexperienced technicians. a) Microscopic Diagnosis Using Stained Thin and Thick Peripheral Blood Smears (PBS)

Malaria is conventionally diagnosed by microscopic examination of stained blood films using

Giemsa, Wright's, or Field's stains105. This method has changed very little since Laverran's original discovery of the malaria parasite, and improvements in staining techniques by

Romanowsky in the late 1,800s. More than a century later, microscopic detection and identification of Plasmodium species in Giemsa-stained thick blood films (for screening the presenting malaria parasite), and thin blood films (for species' confirmation) remains the gold standard for laboratory diagnosis 106. Malaria is diagnosed microscopically by staining thick and thin blood films on a glass slide, to visualize malaria parasites. Briefly, the patient's finger is cleaned with 70% ethyl alcohol, allowed to dry and then the side of fingertip is picked with a sharp sterile lancet and two drops of blood are placed on a glass slide. To prepare a thick blood film, a blood spot is stirred in a circular motion with the corner of the

48 slide, taking care not to make the preparation too thick, and allowed to dry without fixative.

After drying, the spot is stained with diluted Giemsa (1 : 20, vol/vol) for 20 min, and washed by placing the film in buffered water for 3 min. The slide is allowed to air-dry in a vertical position and examination using a light microscope. As they are unfixed, the red cells lyse when a water-based stain is applied. A thin blood film is prepared by immediately placing the smooth edge of a spreader slide in a drop of blood, adjusting the angle between slide and spreader to 45° and then smearing the blood with a swift and steady sweep along the surface.

The film is then allowed to air-dry and is fixed with absolute methanol. After drying, the sample is stained with diluted Giemsa (1 : 20, vol/vol) for 20 min and washed by briefly dipping the slide in and out of a jar of buffered water (excessive washing will decolorize the film). The slide is then allowed to air-dry in a vertical position and examined under a light microscope107. The wide acceptance of this technique by laboratories all around the world can be attributed to its simplicity, low cost, its ability to identify the presence of parasites, the infecting species, and assess parasite density-all parameters useful for the management of malaria. Recently, a study showed that conventional malaria microscopic diagnosis at primary healthcare facilities in Tanzania could reduce the prescription of antimalarial drugs, and also appeared to improve the appropriate management of non-malarial fevers96.

However, the staining and interpretation processes are labor intensive, time consuming, and require considerable expertise and trained healthcare workers, particularly for identifying species accurately at low parasitemia or in mixed malarial infections. The most important shortcoming of microscopic examination is its relatively low sensitivity, particularly at low parasite levels. Although the expert microscopist can detect up to 5 parasites/µl, the average microscopist detects only 50-100 parasites/µl108. This has probably resulted in underestimating malaria infection rates, especially cases with low parasitemia and asymptomatic malaria. The ability to maintain required levels of accuracy in malaria

49 diagnostics expertise is problematic, especially in remote medical centers in countries where the disease is rarely seen109. Microscopy is laborious and ill-suited for high-output use, and species determination at low parasite density is still challenging. Therefore, in remote rural settings, e.g. peripheral medical clinics with no electricity and no health-facility resources, microscopy is often unavailable110. b) Rapid Diagnostic Tests (RDTs)

Since the World Health Organization (WHO) recognized the urgent need for new, simple, quick, accurate, and cost-effective diagnostic tests for determining the presence of malaria parasites, to overcome the deficiencies of light microscopy, numerous new malaria-diagnostic techniques have been developed111. This, in turn, has led to an increase in the use of RDTs for malaria, which are fast and easy to perform, and do not require electricity or specific equipment112. Currently, 86 malaria RDTs are available from 28 different manufacturers113.

Unlike conventional microscopic diagnosis by staining thin and thick peripheral blood smears, and QBC technique, RDTs are all based on the same principle and detect malaria antigen in blood flowing along a membrane containing specific anti-malaria antibodies; they do not require laboratory equipment. Most products target a P. falciparum-specific protein, e.g. histidine-rich protein II (HRP-II) or lactate dehydrogenase (LDH). Some tests detect P. falciparum specific and pan-specific antigens (aldolase or pan-malaria pLDH), and distinguish non-P. falciparum infections from mixed malaria infections. Although most RDT products are suitable for P. falciparum malaria diagnosis, some also claim that they can effectively and rapidly diagnose P. vivax malaria 101,114,115. Recently, a new RDT method has been developed for detecting P. knowlesi 116. RDTs provide an opportunity to extend the benefits of parasite-based diagnosis of malaria beyond the confines of light microscopy, with potentially significant advantages in the management of febrile illnesses in remote malaria- endemic areas. RDT performance for diagnosis of malaria has been reported as excellent

94,99,100,102,117-119; however, some reports from remote malaria-endemic areas have shown wide variations in sensitivity112,120. Murray and co-authors recently discussed the reliability of

RDTs in an "update on rapid diagnostic testing for malaria" in their excellent paper121.

Overall, RDTs appears a highly valuable, rapid malaria-diagnostic tool for healthcare workers; however it must currently be used in conjunction with other methods to confirm the results, characterize infection, and monitor treatment. In malaria-endemic areas where no light microscopy facility exists that may benefit from RDTs, improvements are required for ease of use, sensitivity for non-falciparum infection, stability, and affordability. The WHO is now developing guidelines to ensure lot-to-lot quality control, which is essential for the community's confidence in this new diagnostic tool113. Because the simplicity and reliability of RDTs have been improved for use in rural endemic areas, RDT diagnosis in non-endemic regions is becoming more feasible, which may reduce time-to-treatment for cases of imported malaria110.

2.8.3 Molecular Diagnostic Methods

As mentioned above, traditional malaria diagnostic methods remain problematic. New laboratory diagnostic techniques that display high sensitivity and high specificity, without subjective variation, are urgently needed in various laboratories. Recent developments in molecular biological technologies, e.g. PCR, loop-mediated isothermal amplification

(LAMP), microarray, mass spectrometry (MS), and flow cytometric (FCM) assay techniques, have permitted extensive characterization of the malaria parasite and are generating new strategies for malaria diagnosis.

2.9 TREATMENT OF MALARIA

Malaria is an entirely preventable and treatable disease. The primary objective of treatment is to ensure the rapid and complete elimination of the Plasmodium parasite from the patient’s

51 blood in order to prevent progression of uncomplicated malaria to severe disease or death, and to prevent chronic infection that leads to malaria-related anaemia. From a public health perspective, the goal of treatment is to reduce transmission of the infection to others, by reducing the infectious reservoir, and to prevent the emergence and spread of resistance to antimalarial medicines. Patients with suspected malaria should have parasitological confirmation of diagnosis with either microscopy or rapid diagnostic test (RDT) before antimalarial treatment is started.21 Treatment based on clinical grounds should only be given if diagnostic testing is not immediately accessible within two hours of patients presenting for treatment.21 Prompt treatment within 24 hours of fever onset with an effective and safe antimalarial is necessary to prevent life-threatening complications.21

2.9.1 Objectives of Treatment

Uncomplicated Malaria

The objective of treating uncomplicated malaria is to cure the infection as rapidly as possible.

Cure is defined as the elimination from the body of the parasites that caused the illness.21

This prevents progression to severe disease, and additional morbidity associated with treatment failure. In treatment evaluations, it is necessary to follow patients for sufficient time to appropriately assess cures. The public health goal of treatment is to reduce transmission of the infection to others, i.e. to reduce the infectious reservoir and to prevent the emergence and spread of resistance to antimalaria medicines.21 The adverse effect profile and tolerability of antimalaria medicines and the speed of therapeutic response are also important considerations.

Severe Malaria

The primary objective of antimalarial treatment in severe malaria is to prevent death.In treating cerebral malaria, prevention of neurological deficit is also an important objective.21

In the treatment of severe malaria in pregnancy, saving the life of the mother is the primary objective. In all cases of severe malaria, prevention of recrudescence and avoidance of minor adverse effects are secondary.

2.9.2 Treatment of Uncomplicated Malaria

Definition of Uncomplicated Malaria

Uncomplicated malaria is defined as symptomatic malaria without signs of severity or evidence (clinical or laboratory) of vital organ dysfunction. The signs and symptoms of uncomplicated malaria are nonspecific. Malaria is, therefore, suspected clinically mostly on the basis of fever or a history of fever.

Rationale for Antimalarial Combination Therapy

Antimalarial combination therapy is the simultaneous use of two or more blood schizontocidal medicines with independent modes of action and, thus, different biochemical targets in the parasite. The rationale is twofold: i) the combination is often more effective; and ii) in the very rare event that a mutant parasite resistant to one of the medicines arises de novo during the course of the infection, this resistant parasite will be killed by the other antimalarial medicine.21 This mutual protection is thought to prevent or delay the emergence of resistance. To realize the two advantages, the partner medicines in a combination must independently be sufficiently efficacious in treating malaria.21

Artemisinin-based Combination Therapy

These are combinations in which one of the components is artemisinin and its derivatives

(artesunate, artemether, dihydroartemisinin). The artemisinins produce rapid clearance of parasitaemia and rapid resolution of symptoms, by reducing parasite numbers 100- to 1000- fold per asexual cycle of the parasite (a factor of approximately 10 000 in each 48-h asexual cycle), which is more than what the other currently available antimalarials achieve.21

To eliminate at least 90% of the parasitaemia, a 3-day course of the artemisinin is required to cover up to three post-treatment asexual cycles of the parasite. This ensures that only about

10% of the parasitamia is present for clearance by the partner medicine, thus reducing the potential for development of resistance.21

WHO recommends artemisinin-based combination therapies (ACTs) for the treatment of uncomplicated malaria caused by the P. falciparum parasite.21 By combining two active ingredients with different mechanisms of action, ACTs are the most effective antimalarial medicines available today. WHO currently recommends five ACTs for use against P. falciparum malaria.21 The choice of ACT should be based on the results of therapeutic efficacy studies against local strains of P. falciparum malaria.

ACTs are the mainstay of recommended treatment for P. falciparum malaria and, as no alternative to artemisinin derivatives is expected to enter the market for at least several years, their efficacy must be preserved.21 WHO recommends that national malaria control programmes regularly monitor the efficacy of antimalarial medicines in use to ensure that the chosen treatments remain efficacious. 21

In summary, the ACT options now recommended for treatment of uncomplicated falciparum malaria in alphabetical order are: artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, dihydroartemisinin plus piperaquine.

Artemisinin and its derivatives must not be used as oral monotherapy, as this promotes the development of artemisinin resistance. Moreover, fixed-dose formulations (combining two different active ingredients co-formulated in one tablet) are strongly preferred and recommended over co-blistered, co-packaged or loose tablet combinations, since they

54 facilitate adherence to treatment and reduce the potential use of the individual components of co-blistered medicines as monotherapy.21

P. vivax infections should be treated with chloroquine in areas where this medicine remains effective. In areas where chloroquine-resistant P. vivax has been identified, infections should be treated with an ACT, preferable one in which the partner medicine has a long half-life.

2.9.3 Treatment of Severe Malaria

In a patient with P. falciparum asexual parasitaemia and no other obvious cause of symptoms, the presence of one or more of the following clinical or laboratory features classifies the patient as suffering from severe malaria as was seen in the table above.

The main objective is to prevent the patient from dying. Secondary objectives are prevention of disabilities and recrudescence.

The mortality of untreated severe malaria (particularly cerebral malaria) is thought to approach 100%.21 With prompt, effective antimalarial treatment and supportive care the mortality falls to 15–20% overall; although within the broad definition there are syndromes associated with mortality rates that are lower (e.g. severe anaemia) and higher (metabolic acidosis).21 Death from severe malaria often occurs within hours of admission to hospital or clinic, so it is essential that therapeutic concentrations of a highly effective antimalarial are achieved as soon as possible.21 Management of severe malaria comprises four main areas: clinical assessment of the patient, specific antimalaria treatment, adjunctive therapy and supportive care.21

Clinical Assessment

Severe malaria is a medical emergency. An open airway should be secured in unconscious patients and breathing and circulation assessed. The patient should be weighed or body weight estimated, so that medicines, including antimalarials and fluids, can be given

55 accordingly. An intravenous cannula should be inserted and immediate measurements of blood glucose (stick test), haematocrit/haemoglobin, parasitaemia and, in adults, renal function should be taken. A detailed clinical examination should be conducted, including a record of the coma score. Several coma scores have been advocated. The Glasgow coma scale is suitable for adults, and the simple Blantyre modification or children’s Glasgow coma scale are easily performed in children. Unconscious patients should have a lumbar puncture for cerebrospinal fluid analysis to exclude bacterial meningitis. The degree of acidosis is an important determinant of outcome; the plasma bicarbonate or venous lactate level should, therefore, be measured, if possible. If facilities are available, arterial or capillary blood pH and gases should be measured in patients who are unconscious, hyperventilating or in shock.

Blood should be taken for cross-match, full blood count, platelet count, clotting studies, blood culture and full biochemistry (wherever possible). The assessment of fluid balance is critical in severe malaria. Respiratory distress, in particular with acidotic breathing in severely anaemic children, often indicates hypovolaemia and requires prompt rehydration and, where indicated, blood transfusion.

The differential diagnosis of fever in a severely ill patient is broad. Coma and fever may result from meningoencephalitis or malaria. Cerebral malaria is not associated with signs of meningeal irritation (neck stiffness, photophobia or Kernig sign), but the patient may be opistotonic. As untreated bacterial meningitis is almost invariably fatal, a diagnostic lumbar puncture should be performed to exclude this condition. There is also considerable clinical overlap between septicaemia, pneumonia and severe malaria – and these conditions may coexist. In malaria endemic areas, particularly where parasitaemia is common in the young age group, it is often impossible to rule out septicaemia in a shocked or severely ill obtund child. Where possible, blood should always be taken on admission for culture and, if there is

56 any doubt about the diagnosis, empirical antibiotic treatment should be started immediately along with antimalarial treatment.21

Specific Antimalarial Treatment

It is essential that effective, parenteral (or rectal) antimalarial treatment in full doses is given promptly in severe malaria. Two classes of medicines are available for the parenteral treatment of severe malaria: the cinchona alkaloids (quinine and quinidine) and the artemisinin derivatives (artesunate, artemether and artemotil).21 Parenteral chloroquine is no longer recommended for the treatment of severe malaria, because of widespread resistance.

Intramuscular sulfadoxine-pyrimethamine is also not recommended.21

Various artemisinin derivatives have been used in the treatment of severe malaria, including artemether, artemisinin, artemotil and artesunate. Randomized trials comparing artesunate and quinine from South-East Asia show clear evidence of benefit with artesunate. In a multi- centre trial, which enrolled 1461 patients (including 202 children < 15 years old), mortality was reduced by 34.7% in the artesunate group when compared to the quinine group.21 The results of this and smaller trials are consistent and suggest that artesunate is the treatment of choice for adults with severe malaria. Until recently there was insufficient evidence to make a similar recommendation in children, from high transmission settings, so the guidelines for this important patient group did not recommend artesunate above treatment with either artemether or quinine.21

This has now changed with the publication of the AQUAMAT trial*, a multi-centre study conducted in African children hospitalized with severe malaria.21 This very large randomized controlled trial, which enrolled 5425 children < 15 years of age across Africa, showed a significant mortality reduction by 22.5% in the artesunate group when compared to the quinine group.21 The incidence of convulsions, coma, and hypoglycaemia developing after

57 hospital was also significantly reduced. Importantly there was no significant difference in the incidence of severe neurological sequelae.21

Follow-on Treatment

Following initial parenteral treatment, once the patient can tolerate oral therapy, it is essential to continue and complete treatment with an effective oral antimalarial using a full course of an effective ACT (artesunate plus amodiaquine or artemether plus lumefantrine or dihydroartemisinin plus piperaquine) or artesunate (plus clindamycin or doxycycline) or quinine (plus clindamycin or doxycycline). Doxycycline is preferred to other tetracyclines because it can be given once daily, and does not accumulate in renal failure. But as treatment with doxycycline only starts when the patient has recovered sufficiently, the 7-day doxycycline course finishes after the quinine, artemether or artesunate course.

Where available, clindamycin may be substituted in children and pregnant women; doxycycline cannot be given to these groups. Regimens containing mefloquine should be avoided, if the patient presented initially with impaired consciousness. This is because of an increased incidence of neuropsychiatric complications associated with mefloquine following cerebral malaria. The current recommendation from experts’ opinion is to give parenteral antimalarials in the treatment of severe malaria for a minimum of 24 h, once started

(irrespective of the patient’s ability to tolerate oral medication earlier) or until the patient is about to tolerate oral medication, before giving the oral follow-up treatment.

Pre-referral Treatment Options

The risk of death from severe malaria is greatest in the first 24 h, yet, in most malaria endemic countries, the transit time between referral and arrival at health facilities for one to be able to administer intravenous treatment is usually prolonged; this delays the commencement of appropriate antimalarial treatment. As during this time the patient may

58 deteriorate or die. it is recommended that patients be treated with the first dose of one of the recommended treatments before referral (unless the referral time is less than 6 h).

Recommended prereferral treatment options include intramuscular artesunate, artemether, or quinine, or rectal artesunate.21 Evidence from recent studies demonstrates that in situations where parenteral medication is not possible and intramuscular injection impractical, using a single dose of rectal artesunate as pre-referral treatment reduces the risk of death or permanent disability in young children.21

2.10 MALARIA PREVENTION AND CONTROL

2.10.1 Insecticides Treated Bed Nets

Insecticide-treated bed Nets (ITNs) are a form of personal protection that has been shown to reduce malaria illness, severe disease, and death due to malaria in endemic regions. In community-wide trials in several African settings, ITNs have been shown to reduce the death of children under 5 years from all causes by about 20%.Insecticide-treated nets are estimated to be twice as effective as untreated nets and offer greater than 70% protection compared with no net.122 Between 2000 and 2008, the use of ITNs saved the lives of an estimated

250,000 infants in Sub-Saharan Africa.123 Although ITNs prevent malaria, only about 13% of households in Sub-Saharan countries own them.124 A recommended practice for usage is to hang a large "bed net" above the center of a bed to drape over it completely with the edges tucked in. Pyrethroid-treated nets and long-lasting insecticide-treated nets offer the best personal protection, and are most effective when used from dusk to dawn.125

Nets may vary by size, shape, colour, material, and/or insecticide treatment status. Most nets are made of polyester, polyethylene, or polypropylene.126

Only pyrethroid insecticides are approved for use on ITNs. These insecticides have been shown to pose very low health risks to humans and other mammals, but are toxic to insects

59 and knock them down (kill them), even at very low doses.126 Pyrethroids do not rapidly break down unless washed or exposed to sunlight. Previously, nets had to be retreated every 6 to 12 months, or even more frequently if the nets were washed. Nets were retreated by simply dipping them in a mixture of water and insecticide and allowing them to dry in a shady place.

The need for frequent retreatment was a major barrier to widespread use of ITNs in endemic countries. In addition, the additional cost of the insecticide and the lack of understanding its importance resulted in very low retreatment rates in most African countries.126

Long-Lasting Insecticide-treated Nets (LLINs)

Several companies have developed long-lasting insecticide-treated nets (LLINs) that maintain effective levels of insecticide for at least 3 years, even after repeated washing. The WHO

Pesticide Evaluation Scheme (WHOPES) has given either full or interim approval to 13 of these LLINs for use in the prevention of malaria. CDC is currently testing some of these and other LLINs to assess their performance and durability in the field.126

LLINs have been associated with sharp decreases in malaria in countries where malaria programs have achieved high LLIN coverage. WHO now recommends that LLINs be distributed to and used by all people ("universal coverage") in malarious areas, not just by the most vulnerable groups: pregnant women and children under 5 years. LLINs are most commonly distributed through mass campaigns approximately every 3 years.126

Between 2008 and 2010, a total of 294 million nets were distributed in sub-Saharan Africa.

Funding for LLINs has gradually increased from 2004 when 5.6 million nets were delivered, to 2010, when 145 million nets were delivered.126 However, funding for nets, and other malaria prevention and control interventions, is likely to plateau or even decline in the next few years due to the current economic situation. One way to maintain net coverage is to

60 increase the lifespan of LLINs. A recent study estimated that up to $3.8 billion could be saved over 10 years by increasing the lifespan of nets from 3 years to 5 years.126

2.10.2 Insecticide Spraying

Many malaria vectors are considered "endophilic"; that is, the mosquito vectors rest inside houses after taking a blood meal.126 These mosquitoes are particularly susceptible to control through indoor residual spraying (IRS). IRS involves coating the walls and other surfaces of a house with a residual insecticide. For several months, the insecticide will kill mosquitoes and other insects that come in contact with these surfaces. IRS does not directly prevent people from being bitten by mosquitoes. Rather, it usually kills mosquitoes after they have fed if they come to rest on the sprayed surface. IRS thus prevents transmission of infection to other persons. To be effective, IRS must be applied to a very high proportion of households in an area (usually >80%).IRS is a major intervention for malaria control.126

As of 2006, the World Health Organization recommends 12 insecticides in IRS operations, including DDT and the pyrethroids cyfluthrin and deltamethrin.127 This public health use of small amounts of DDT is permitted under the Stockholm Convention on Persistent Organic

Pollutants (POPs), which prohibits its agricultural use.128 One problem with all forms of IRS is insecticide resistance. Mosquitoes affected by IRS tend to rest and live indoors, and due to the irritation caused by spraying, their descendants tend to rest and live outdoors, meaning that they are less affected by the IRS.129

DDT has several characteristics that are of particular relevance in malaria vector control. Among the 12 insecticides currently recommended for this intervention, DDT is the one with the longest residual efficacy when sprayed on walls and ceilings (6–12 months depending on dosage and nature of substrate).130

In similar conditions, other insecticides have a much shorter residual efficacy (pyrethroids:

3–6 months; organophosphates and carbamates: 2–6 months). Depending on the duration of the transmission season, the use of DDT alternatives might require more than two spray

61 cycles per year, which would be very difficult (if not impossible) to achieve and sustain in most settings.130

DDT has a spatial repellence and an irritant effect on malaria vectors that strongly limit human-vector contact. Vector mosquitoes that are not directly killed by DDT are repelled and obliged to feed and rest outdoors, which contributes to effective disease-transmission control.130

2.10.3 Vector Control

Interventions targeting the larval stages of the mosquito are used in developing countries.

While these interventions can be popular, the evidence for their effectiveness is generally weak and there is a critical need for more rigorous evaluation of the ecological settings in which they might have an impact on reducing malaria transmission.126

Theoretically, larval control would seem to be an ideal approach to mosquito control as it eliminates mosquitoes before they reach the stage where they can transmit malaria. However, larval habitats may be small, widely dispersed, and transient.126

Anopheles gambiae, one of the primary vectors of malaria in Africa, breeds in numerous small pools of water that form due to rainfall. The larvae develop within a few days, escaping their aquatic environment before it dries out. It is difficult, if not impossible, to predict when and where the breeding sites will form, and to find and treat them before the adults emerge.

Therefore, larval mosquito control for the prevention of malaria in Africa has not been attempted on a large scale. It may, however, be appropriate for specific settings such as urban environments or desert fringe areas where habitats are more stable and predictable126. WHO recently recommended larval control as appropriate for areas where the larval habitats are

"few, fixed, and findable."126

Larval control may be implemented through source reduction, chemical larviciding, and through biological control.Other vector control interventions include fogging or area spraying, sterile male release and genetic modification of malaria vectors.

2.10.4 Malaria Vaccine

Although progress has been made in the last 10 years toward developing malaria vaccines, there is currently no effective malaria vaccine on the market.126 The development of a malaria vaccine has faced several obstacles: the lack of a traditional market, few developers, and the technical complexity of developing any vaccine against a parasite.

Malaria parasites have a complex life cycle, and there is poor understanding of the complex immune response to malaria infection. Malaria parasites are also genetically complex, producing thousands of potential antigens. Unlike the diseases for which we currently have effective vaccines, exposure to malaria parasites does not confer lifelong protection.

Acquired immunity only partially protects against future disease, and malaria infection can persist for months without symptoms of disease.126

More than a dozen vaccine candidates are now in clinical development, and one,

GlaxoSmithKline Biologicals’ RTS,S, is in Phase III clinical testing, the first malaria vaccine candidate to advance this far.126Children ages 5-17 months were enrolled in the trial at 11 sites in seven African countries. CDC, in collaboration with the Kenya Medical Research

Institute, led the trial at one site in western Kenya.126

The trial’s first results, made available in October 2011, are a promising advance in development of a malaria vaccine for African children, which, if successful, could save hundreds of thousands of lives. The RTS,S vaccine reduced clinical and severe cases of malaria by half in children who received the vaccine.126

Notably, the vaccine provided this protection in settings where there is ongoing use of other effective malaria prevention and treatment interventions: bed nets, antimalarial drugs, indoor residual insecticide spraying to prevent mosquito-borne transmission, and drugs to protect pregnant women and their newborns from malaria's adverse effects.126

Still to come are analyses of how well the RTS,S/AS01 vaccine works in young infants (aged

6-12 weeks) when provided with their routine childhood immunizations, and how long the vaccine is protective. These results are expected in 2012 and 2014, respectively, and will be critical to understanding how the vaccine may be used to control malaria.126

The world’s leading global health organizations have developed the Malaria Vaccine

Technology Roadmap for accelerating development of a highly effective malaria vaccine.

The roadmap has two goals: Develop and license a first-generation vaccine by 2015 that reduces the risk of severe malaria disease and death by 50% and that protects longer than one year. Develop a malaria vaccine by 2025 that would have a protective efficacy of more than

80 percent against clinical disease and that would provide protection for longer than four years. The recently released RTS,S results show we are on track to meeting that first goal. To meet the second will required a second-generation RTS,S vaccine or a different vaccine altogether.126

2.10.5 Malaria Chemoprophylaxis

Several drugs, most of which are also used for treatment of malaria, can be taken preventively. Generally, these drugs are taken daily or weekly, at a lower dose than would be used for treatment of a person who had actually contracted the disease. Use of prophylactic drugs is seldom practical for full-time residents of malaria-endemic areas, and their use is usually restricted to short-term visitors and travellers to malarial regions. This is due to the

64 cost of purchasing the drugs, negative side effects from long-term use, and because some effective anti-malarial drugs are difficult to obtain outside of wealthy nations.131

Quinine was used starting in the seventeenth century as a prophylactic against malaria. The development of more effective alternatives such as quinacrine, chloroquine, and primaquine in the twentieth century reduced the reliance on quinine. Today, quinine is still used to treat chloroquine resistant Plasmodium falciparum, as well as severe and cerebral stages of malaria, but is not generally used for prophylaxis.131

Modern drugs used preventively include mefloquine (Lariam), doxycycline (available generically), and the combination of atovaquone and proguanil hydrochloride (Malarone).

The choice of which drug to use depends on which drugs the parasites in the area are resistant to, as well as side-effects and other considerations. The prophylactic effect does not begin immediately upon starting taking the drugs, so people temporarily visiting malaria-endemic areas usually begin taking the drugs one to two weeks before arriving and must continue taking them for 4 weeks after leaving (with the exception of atovaquone proguanil that only needs be started 2 days prior and continued for 7 days afterwards).131

2.10.6 Intermitent Preventive Malaria Theraphy (IPT)

Antimalarial drugs have been used in various ways to prevent malaria in the resident populations of endemic areas for nearly 100 years.21 The primary aim of most early studies was to interrupt transmission. Chemoprophylaxis is highly effective in reducing mortality and morbidity from malaria in young children and pregnant women living in endemic areas, but is difficult to sustain and, in some studies, has impaired the development of naturally acquired immunity.21

Intermittent preventive treatment (IPT) describes the administration of a full therapeutic course of an anti-malarial to at risk subjects at specified times regardless of whether they are

65 infected or not.21 IPT differs from chemoprophylaxis, which aims to sustain blood levels above the mean inhibitory concentration for a prolonged period, in producing protective drug concentrations for only short periods of time separated by periods when drug concentrations are below the level necessary to inhibit parasite growth.21 IPT is now a recommended approach to the prevention of malaria in pregnancy (sometimes called IPTp), and is administered at antenatal clinic visits. IPT is being explored as a potential way of preventing malaria in infants (IPTi), potentially linked with routine immunisation schedules. IPT in young children (IPTc) is the subject of new research.21

Sulfadoxine-pyrimethamine (SP) is the drug that has been used most widely for IPT in both pregnant women and children, but it is not known whether IPT achieves its effect primarily by elimination of already present parasites or through the long-acting, prophylactic effect of

SP. However, because of rapidly increasing resistance, it is unlikely that IPT in pregnancy with SP will in future remain as effective as it was in East Africa 5-10 years ago when first evaluated.21 Amodiaquine and SP are being tested for IPT in infants. More effective antimalarial drugs such as artemether-lumefantrine and dihydroartemisinin-piperaquine should be evaluated for IPT in both low- and high-transmission settings21.

Factors that determine whether IPT should be used in certain populations include:

(1) whether intermittent preventive treatment adds to the protection afforded by

other control measures such as insecticide-treated mosquito nets;

(2) whether an effective and sustainable delivery system can be found;

(3) choice of drug to be used;

(4) optimum timing of drug administration;

(5) the requisite interval between treatments.

The potential benefits of intermittent preventive treatment in children are substantial; more research is needed to determine if this is a practical approach to malaria control.21

2.10.7 Seasonal Malaria Chemoprevention (S M C)[i.e IPTc].

Across the Sahel sub-region most childhood malaria mortality and morbidity occurs during the rainy season, which is generally short. Giving effective malaria treatment at intervals during this period has been shown to prevent illness and death from malaria in children.11

Key interventions currently recommended by WHO for the control of malaria are the use of insecticide treated nets (ITNs) and/or indoor residual spraying (IRS) for vector control, and prompt access to diagnostic testing of suspected malaria and treatment of confirmed cases.

Additional interventions which are recommended in areas of high transmission for specific high risk groups include Intermittent Preventive Treatment in pregnancy (IPTp), and

Intermittent Preventive Treatment in infancy (IPTi).11

With the changing epidemiology of malaria, there is a progressive paradigm shift from a “one size fits all” approach, to the targeting of malaria control strategies to specific populations and/or locations for maximal effectiveness. In keeping with this approach, WHO is now recommending a new intervention against Plasmodium falciparum malaria: seasonal malaria chemoprevention (SMC). This intervention has been shown to be effective, cost-effective, safe, and feasible for the prevention of malaria among children less than 5 years of age in areas with highly seasonal malaria transmission.11

Seasonal malaria chemoprevention (SMC) previously referred to as Intermittent preventive treatment in children (IPTc) is defined as the intermittent administration of full treatment courses of an antimalarial medicine during the malaria season to prevent malarial illness with the objective of maintaining therapeutic antimalarial drug concentrations in the blood throughout the period of greatest malarial risk.132

SMC differs from chemoprophylaxis, which aims to sustain blood levels above the mean inhibitory concentrations for a prolonged period, in producing protective drug concentrations for only short period of time, separated by periods when drug concentrations are below the level necessary to inhibit parasite growth. IPT is now a recommended approach to the prevention of malaria in pregnancy (IPTp) and is administered at antenatal clinic visits. IPT is being explored as a potential way of preventing malaria in infants (IPTi), potentially linked with routine immunization schedules. IPT in young children (IPTc) is the subject of new research21.

A group of researchers who have worked on IPTc established a task force (IPTc Working

Group) to collate and summarize data on the efficacy, safety, tolerability, acceptability and affordability of IPTc.132

As a first step in the policy making process of the Global Malaria Programme (GMP), the

Technical Expert Group (TEG) on Preventive Chemotherapy was convened to review the evidence compiled by the IPTc Working Group. The objective was to formulate recommendations which will be presented to the newly established Policy Advisory

Committee of the Department in order to formulate a WHO policy on the role of SMC as a potential in malaria control strategy for children.

The specific objectives of the consultation were:

To review the current evidence on efficacy, safety and large-scale implementability of SMC, and assess the risks and potential benefits of SMC for use as an additional malaria control strategy in different malaria epidemiological settings.

Based on this assessment, to advise WHO on the potential role of SMC as a malaria control strategy.

To identify the critical gaps in knowledge and priority research agendas for the implementation of SMC as a WHO malaria control strategy if recommended.132

Eight randomized controlled trials (7 published and 1 unpublished) in children aged between

3 and 59 months during the rainy season comparing treatment doses of amodiaquine- sulfadoxinepyrimethamine (AQ-SP) at monthly or two monthly intervals versus no treatment conducted in several countries in west Africa were included in the analysis for protective efficacy. The end points for the analysis were

Uncomplicated clinical malaria (defined as fever or a history of fever plus any level of

P.falciparum parasitaemia) during the period of drug administration and one month following the last SMC course.

Severe malaria (defined as per the WHO definition during the period of drug administration and one month following the last SMC course).

Moderate anaemia (Hb < 8g/dL) at the cross-sectional survey at the end of the intervention period (approximately one month following the last SMC course).

All-cause mortality during the period of drug administration and one month following the last

SMC course.132

The summary of some of the conclusions of the evidence review by the TEG are as follows:

Age based dosing schemes used either a half or whole tablet. There was no association between efficacy and the dose of SP given, however there was an association between AQ dose and malaria incidence, the effect being most marked in children under 2 years of age.

There is evidence of a moderate increase in the incidence of vomiting when the dose of AQ given exceeds the maximum recommended value (>15mg/kg daily). To ensure maximum efficacy balanced with tolerability, and for effective wide-scale deployment, a dosing scheme using either a half or a whole tablet is ideal. For AQ, a regimen of ½ of a 153mg tablet should

69 be used in infants <12 months old, and a full tablet in those aged 12-59 months. Use of a similar age regimen for SP tablets ensures that the majority of children receive the recommended minimum SP dose of 25/1.25mg/kg.132

Analysis of the costs of delivering SMC suggest that in areas where the incidence of malaria in children in the target age group is above 0.2 attacks of malaria per transmission season,

SMC will be a highly cost-effective intervention as assessed by both the cost of a case and a

DALY prevented. In areas where the incidence of clinical attacks of malaria in children is between 0.1 and 0.2 attacks per transmission season, SMC may still be an attractive option although relatively more expensive. At an incidence rate of less than 0.1 clinical attacks per transmission season, SMC is unlikely to be a cost effective intervention.132

The committee made the following recommendations -

A complete treatment course of AQ+SP at monthly intervals to a maximum of four doses during the malaria transmission season should be given to children aged between 3 and 59 months as Seasonal Malaria Chemoprevention in areas of highly seasonal malaria transmission across the West Africa Sahel Sub-Region (where both drugs retain sufficient antimalarial efficacy).

Target areas for implementation are areas where

a) more than 60% of clinical malaria cases occur within a maximum of 4 months,

b) the clinical attack rate of malaria is greater than 0.1 attack per transmission season in

the target age group, and

c) AQ+SP remains efficacious (>90% efficacy*)

(*Note in some countries, the eligibility for SMC deployment might apply only to part of their malaria endemic area).

A complete treatment course of AQ+SP should be dosed at monthly intervals to a maximum of 4 doses a year (transmission season). The recommended dosing schedule is AQ - ½ of a

153mg tablet for infants <12 months old, and a full tablet in those aged 12- 59 months given once daily for three days; and a single dose of SP - ½ of a 500/25mg tablet for infants and a full tablet for children aged between 12 and 59 months.

Administration of at least the first dose of AQ and the SP dose must be directly observed, and efforts to ensure adherence to the full three day course of AQ strengthened.

For maximum protection and to minimize selection for drug resistance, children should receive preventive treatments each month during the transmission period, and should comply to the complete 3-days treatment course each month.

Treatment of breakthrough malaria infection during the course of SMC should not include either AQ or SP.

Intermittent Preventive Treatment with SP in infancy and SMC should not be administered concomitantly. Therefore in target areas for SMC, IPTi should not be deployed.

SMC Contraindications includes HIV positive children receiving co-trimoxazole, subject has received a dose of either AQ or SP drug during the past month, Allergy to either drug (AQ or

SP).

Other considerations includes:

While there are several potential approaches to implement this strategy, there is presently insufficient evidence to recommend a standard deployment strategy. However, the committee strongly recommends integration into existing programmes, such as the integrated

Community Case Management and other Community Health Workers schemes.

In areas where SMC is deployed, pharmacovigilance should be strengthened or instituted, drug resistance monitoring and system evaluation should be supported or instituted, including

71 systems to assess the number of breakthrough infections and their intervals from the last dose of SMC, the health system needs to record and monitor AQ+SP doses administered in order to evaluate the impact of the intervention. Existing systems to document severe malaria, malaria deaths, and record confirmed cases of malaria should be strengthened.132

A randomized placebo controlled trial study on seasonal intermittent preventive treatment for the prevention of anaemia and malaria in Ghanaian children where artesunate plus amodaquine (AS + AQ) given monthly and bimonthly or SP bimonthly over a period of six months. The primary outcome measures were episodes of anaemia (Hb<8.0gldl) or malaria detected through passive surveillance. Monthly artesunate + amodaqume reduced the incidence of malaria by 69% and anaemia by 45% while bimonthly SP reduced the incidence of malaria by 24% and anaemia by 30%, and bimonthly artesunate and amodaquine reduced the incidence of malaria by 17% and anaemia by 32%133.

Another study on IPT in children using SP-Amodaquine conducted in Mali to see if IPT provides substantial protection against malaria in children already protected by insecticide – treated bed net revealed that IPTc given monthly during the malaria transmission (from

August to October) season provided substantial protection against clinical episodes of malaria, malaria infection, and anaemia in children using an long lasting insecticide treated net (LLIN) 134.

A similar study on the effectiveness of combined intermittent preventive treatment for children and timely home treatment for malaria control in Ghana in which all children between 6 and 60months of age received intermittent preventive treatment using amodaquine and artesunate delivered every 4months (3times in 12months) and home treatment of suspected febrile malaria illness in 24hrs. The evaluation result indicates that IPTc given three times in a year combined with timely treatment of febrile malaria illness, impacts significantly on the parasite prevalence. (That is reducing the parasite prevalence from 25%

72 to 3%). The marked reduction in the parasite prevalence with this strategy points to the potential for reducing malaria related childhood morbidity and mortality.135

A study carried out by Collins K Ahorlu and Kwadwo A Koram on intermittent preventive treatment for children (IPTc) combined with timely home treatment for malaria control showed a signicant reduction in malaria prevalence from 25% at baseline to 1% at year- two evaluation .At baseline, 13.8% of the children were febrile (axillary temperature of ≥ 37.50C) compared to 2.2% at year-one evaluation while about 2.0% were febrile at year two evaluation.136

The use of sulphonamide in combination of pyrimethamine for the treatment of malaria goes back to the early seventies when Hoppman-La-Roche introduced the drug Fansidar®. It was recommended to use this combination as follows: three tablets containing 500mg sulphadoxine and 25mg pyrimethamine, as a single dose. Both SP and sulphamethoxypyrazine – pyrimathemine (SMP) have been used in Africa for many years and were only recently stopped being recommended for the curate treatment of malaria in some Africa countries in favour of arternisinin – based combination therapy (ACT) 137.

While resistance to older antimalarials is increasingly common, newer antimalaria are still not widely available or affordable in much of Africa.138The combination of SP was selected by some for intermittent therapy in infant children and in pregnant women. Both why SP was preferred over SMP is not clear. Both sulphonamide are relatively safe.137

SP and SMP act by inhibiting the folic acid biosynthesis of the parasite (but also of bacteria) at two levels. First, the sulphonamide acts as a competitive inhibitor with P-amino benzoic acid in the first part of the synthesis of folic acid. At a later stage, pyrimethamine interferes with the dihydrofolate reductase enzyme necessary to reduce the intermediate compound dihydrofolate into folic acid. SP has a longer elimination half life (about 200h but variable)

73 and a very high binding to plasma proteins (between 95 and 99%). Since for sulphonamide therapy only the non-protein bound parts of the drug (the so called free fraction which distributes in all body compartments) is active against bacteria and parasites, a much larger dose of SP (i.e. 1500mg) is usually given.137

SP is the drug that has been used most widely for IPT in both pregnant women and children, but it is not known whether IPT achieves it’s effect primarily by elimination of already present parasites or through the long-acting, prophylactic effect of SP.137

CHAPTER THREE

3.0 MATERIALS AND METHODS

3.1 STUDY AREA

Jengre is a semi-urban town in Bassa Local Government Area in the north of Plateau State,

Nigeria, bordering Kaduna and Bauchi State. The Seventh Day Adventist Hospital is a comprehensive Hospital that offers both primary and secondary health care to the people of

Plateau State and adjoining states of Kaduna and Bauchi. The study was carried out in the general out-patient department in Seventh Day Adventist Hospital. The unit is usually run by medical officers, community health extension workers and family medicine residents from

Jos University Teaching Hospital. Most caregivers of children attending the outpatient clinic understand and speak English, Hausa and a host of other native dialects common to the people of the area. The people of Jengre are mostly engaged in farming, trading, carpentry, tailoring, mechanic etc. Mild ailments are treated in the clinic while serious cases are referred to the specialist at the Jos University Teaching Hospital.

3.2 PERIOD AND DURATION OF STUDY

This study was carried out between July and December 2014. It was commenced at the peak of the rainy season when malaria transmission was high.

3.3 STUDY POPULATION

Children between the age of 1 to 5years within the study area presenting for their normal routine under five clinic who were at risk of developing malaria but did not have clinical malaria or anaemia as defined.

3.4 ELIGIBILITY

3.4.1 Inclusion Criteria

1. Children between one and five years of age resident in the selected community

presenting for routine under-five clinic.

2. Children likely to be available for follow–up during the season of high malaria

transmission.

3. Assent by Children and consent by parents / guardian of child.

3.4.2 Exclusion Criteria

1. History of hypersensitivity to any of the study drugs.

2. Signs and symptoms of malaria at the time of the study recruitment.

3. Presence of anaemia (Hb<10grams per deciliters) at recruitment.

4. Any known chronic illness e.g. tuberculosis, diabetes mellitus, renal failure, severe

malnutrition (i.e. weight for age <60%).

5. Permanent disability like sickle cell disease that will prevent or impede study

participation.

3.5 STUDY HYPOTHESIS

The study hypothesis was that sulphadoxine-pyrimethamine administered intermitently to children under the age of 5 during the season of high malaria transmission (i.e. from July to

October) had a protective efficacy on the haematocrit count and clinical malaria.

3.6 STUDY DESIGN

The study was a randomized controlled trial.

3.7 SAMPLE SIZE DETERMINATION

Study Characteristics Assumption Made

Type of study Randomized controlled trial

Data Sets Observation in one experimental group (E) and one control

group (C) of the same size.

Expected outcomes P (C ) = 40% or 0.40139

P ( E) = 20% or 0.20

Variables Effect of IPTc on the incidence of malaria and anaemia

Data for alpha (zα) P = 0.05 therefore, 95% confidence desired (two-tailed

test); zα = 1.96

Data for beta (zβ) 20% beta error, therefore, 80% power desire (one-tailed

test), zβ=0.84.

Difference to be detected (ḋ) 0.2 or larger difference between the success (reduced

clinical malaria and anaemia) of the experimental group

and that of control group (i.e 20% difference because

PE= 0.40, PC= 0.20

- - - P = P E + P C 2

Variance of proportion expressed as P- (1-P) P- = 0.3; therefore, (1 – P) = 0.70 therefore, using the formula for test of difference and proportion and considering alpha and beta errors;

Sample size (N) = (z훼 + zβ)2 x 2 x P (1-P) (-d)2

Where N = sample size of each group, Z훼 = value for alpha error = 1.96, zβ= value for beta error = 0.84 (Both Z훼 and Zβ values are read from a standardized normal distribution table); 2

– constant for an unpaired data, P = mean of proportion of success = 0.3 and d = difference to be detected = 0.20.

That is, N = (1.96 +0.84)2 x 2 x 0.3 (1 – 0.3) (0.20)2

N = 3.29 = 82.25 0.040

Sample size = 82.25 subjects per group x 2 = 164.5 Assuming a 10% maximum attrition rate, additional 10% which is 16.54 will be recruited giving a total of 181.04 or 182.

3.8 ETHICAL CONSIDERATIONS

An approval was obtained from the JUTH Ethical Committee and written informed consent was obtained from eligible assenting patients and consenting care givers for subjects aged between one to five years.

3.9 STUDY PROCEDURE

All care-takers of children aged 1-5years were invited and informed consent for inclusion of their child in the study was sought and the study explained to them. All those who gave consent had their basic information collected using a questionnaire which was interviewer administered. Anthropometric indices were measured and blood samples were taken from each child using a heel prick for estimation of parasite density and packed cell volume. All eligible children were included.

The baseline information were the child’s demographic information and history of fever, vomiting, diarrheoa, maternal educational level, family history and use or non use of mosquito net.

The weight and height were taken after calibration of the weighing scale and stadiometer

(RTZ-120A Health Scale 120 x 0.5kg , made by Techmel & Techmel Texas USA). The weighing scale was calibrated using a standard mass of known weight in kilograms (a 10kg mass). The child was undressed leaving only light underwear and then placed on a Bathroom weighing scale to determine the weight .The height was taken by asking the child to stand in front of a stadiometer with the footwear removed and the reading was read at right angle on the meter above the child’s head. General examination on the children to exclude jaundice and clinical anaemia were carried out. The axillary temperature was also noted using the mercury thermometer which should not exceed 37.50c. The heel of the child was pricked by a

78 trained laboratory scientist and a thick film was prepared for malaria parasite density. The haemocrit was also assessed using the Hawkley haematocrit reader (made in England by

Hawkley and sons limited).

Thick films were prepared by placing drops of blood on clean microscope slides and with the corner of a second slide, the blood was spread until it was about 1cm in diameter. A film was adjudged as good quality once news print could be seen through it.

Thin films was prepared by allowing drops of blood on clean microscope slides to flow on the edge of a second slide and quickly spread using the edge of the second slide over the first slide until the blood thinned out. The films were allowed to dry. They were then stained with freshly prepared 4% Giemsa stain for 10 minutes at a PH of 7.3.

Microscopic examinations of the slides (microscope model –Olympus CH20) were done by the investigator, a trained laboratory technician from the Department of Medical

Microbiology, Jos University Teaching hospital. The slides were read by both the researcher and the trained laboratory technician. An oil immersion microscope eye piece of x 100 magnification was used. Positive slides were identified and parasite densities were calculated by counting the number of asexual parasites against 200 white blood cells (WBC) in the thick film using a hand tally counter (model NJ07054, Clay Adams, USA). Parasite density, expressed as the number of asexual parasites per microliter (μl), was calculated by dividing the number of asexual parasites by the number of WBCs counted and then multiplied by an assumed WBC density of 8000 WBCs/μl. When gametocytes were seen they were counted and the parasite density calculated.

Packed cell volume was done using blood in a heparinized capillary tube which was centrifuged in a micro centrifuge (High Speed Microhematocrit Centrifuge, Model= SH120, made by Medifield Equipment and Scientific, England.) at 5000 revolutions per minute for 5

79 minutes and the result was read on a haematocrit reader (Hawkley, made in England by

Hawkley and sons).

3.10 RECRUITMENT AND ALLOCATION

Consecutive patients attending the child welfare clinic were screened those that met the study inclusion criteria were recruited and randomized in two groups. Randomization was done using open computer generated random numbers which were placed separately in opaque envelopes. All caregivers were to pick numbers from these envelopes and those with odd numbers were allocated to group A (Intervention) while those with even numbers were allocated to group B(Control). Both groups received health education and were counselled on use of ITN bed nets.

Children in the experimental group (groupA) received a dose of sulphadoxine-pyrimethamine

(SP) on the 1st day of presentation when they came for their routine monthly under-five clinic. Each dose of S-P was administered according to the child’s weight in kilograms to avoid sub-optimal dosing.

To facilitate drug administration in small children, tablets were crushed in a spoon and given with water which was sweetened. All participants were kept under observation for 10-15mins after drug intake. The drug was re-administered to participants that had vomiting immediately after drug administration. The heel of the child was pricked and samples were taken in a capillary tube and a thick film was prepared. The sample in a capillary tube and the thick film were sent to the laboratory for haematocrit and malaria parasite density respectively. The slides that were prepared were read by the trained laboratory scientist and the researcher.

3.11 DEFINITION OF TERMS

Incidence: Is the frequency (number) of new occurrences of disease (Malaria). That is the number who becomes ill in the study population during the time of the study.

Severe Falciparum malaria: Acute falciparum malaria with signs of severity and/or evidence of vital organ dysfunction. The presence of one or more of the clinical or

Laboratory features classifies the person as suffering from severe malaria.21The laboratory parameters used in this study were parasite count ≥ 250,000 cells and Packed Cell Volume of

≤ 15%.

Clinical Anaemia: A haemoglobin level of less than 10g per deciliter (Packed Cell Volume

Less Than 30% Percent) or presence of signs (Pallor, shortness of breath, tachypnoea) in children in this age group.22

3.12 FOLLOW-UP PROCEDURE

The study participants were seen again when they presented four weeks later for routine under-five clinic and 2nd visit questionnaire were administered to probe for any history of malaria or date of treatment for malaria. They were examined again as in the first visit. The second dose of S-P was then administered as in the first visit and again blood samples were taken for the haematocrit and malaria parasite density as in the first visit. They were similarly reviewed in the third visit( i.e four weeks after the 2nd visit) and a third visit questionnaire was administered as in the 2nd visit. They also had 3rd dose of S-P. Participants were expected

81 to come four weeks after the 3rd visit during which no further treatment was given but a sample was taken for haematocrit and malaria parasite density.

3.13 CONTROL GROUP

They were also reviewed monthly as they presented for their routine under-five clinic. During those visits, they were administered the same questionnaire and examined as in the experimental group but they were not given any treatment. They also had their blood samples taken as in the experimental group for malaria parasite density and haematocrit.

For any of the study participants that presents to the clinic with signs and symptoms of malaria, irrespective of the study group, their blood samples were taken and blood film were prepared and read for malaria parasite and haematocrit.

Those that had clinical malaria were treated orally with arthemeter plus lumefanthrin

(Coartem ®) if they are not actively vomiting. Intravenous artesunate 2.4mg/kg 12hrly were administered to those that were actively vomiting until their vomiting stops then they were followed up on 3 days course of oral ACT if they could take orally. Those that were treated were presumed to be protected for 28 days. Drugs for treatment of malaria was provided free of charge for the study population by the researcher. All cases of clinical malaria attacks treated within the study period were documented. Adverse events were also noted and documented. The cost of administering a monthly dose of antimalarial and treatment of malaria in the study population was compared with the amount used for treatment in the control group to establish any cost- benefits. They were seen at least 4 times during the study, at the 1st month (Baseline), 2nd month, 3rd month and then, again, after 1 month to assess the impact.

3.14 DRUG DOSAGES AND SCHEDULE

Monthly sulphadoxine-pyrimethamine at dosages of 25mg/kg of sulphadoxine and 1.25mg/kg of pyrimethamine manufactured by Swipha.The doses were as follows :

a) (5 – 10kg) = ½ tablet

b) 1 – 5 years = 1 tablet

3.15 METHOD OF DATA ANALYSIS

Data was analyzed on an intention to treat basis including all children who were enrolled.

Time at risk was started at enrolment, at the time the first dose was administered. Children were not judged at risk for 28days after treatment for a malaria attack. Kaplan Meier analysis was used to compare the time to the first malaria attack after intervention. The Students ‘t’test was used to compare mean values between study groups. Descriptive statistic(frequencies and percentages) was used to determine the incidence between groups. The incidence rate ratio

(IRR) was computed by dividing the incidence in the intervention group by the incidence in the control group. The Protective Effect was computed using the formula (1- Incidence rate ratio (IRR)). The chi-square test was used to analyze statistical association between groups and Epi-info software version 3.5.3 (CDC, Altanta, and Georgia,) was used for data analysis.

3.16 DURATION OF THE STUDY

The study began in July and ended in December 2014. It took one week to recruit 50 patients; and then one month to recruit 200 subjects.

3.17 INCENTIVES

The drug (SP) and laboratory tests were free. Free antimalarial (ACT) was administered to study participants that came down with malaria in the course of the study. Patients were counselled on the importance of adhering to regular use of insecticide treated bed nets as well as keeping a clean environment. The researcher bore the cost for the drugs and laboratory investigation.

CHAPTER FOUR

4.0 RESULTS

At recruitment, two hundred children were found eligible. One hundred and eighty two subjects were sampled and studied. There were few subjects that were lost to follow up after recruitment into the study (four in the intervention arm and seven in the control arm). The reason being that the study participants in the community all lived close to the hospital and the religious centres would help to mobilize the subjects through announcement prior to their next visit. In addition phone calls were used to mobilize those that forgot their appointment.

The incentives also helped to encourage the study participants to come for follow up.

One hundred and seventy one subjects completed the study (87 in the intervention arm and 84 in the control arm).Nine subjects (two in the intervention arm and seven in the control arm) had severe malaria and could not complete the study. No subject had any adverse effect to the drugs during the study period to warrant exclusion from the study after recruitment.

Figure 4.1; Patient flow chart

200 SUBJECTS ELIGIBLE

182 SUBJECTS SAMPLED

Randomization

91 subjects 91 subjects Intervention Control (Baseline)

4 were lost to follow nd rd th 7 were lost to follow up on up 2 , 3 and 4 visit account of severe malaria 87 subjects 84 subjects Completed the Completed the study study

91 subjects 91 subjects Based on intention to analyzed analyzed treat

4.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS

4.1.1 Age

The overall mean age of the study group was 23.25±12.65 months. The age range of participants was 12-60 months (1-≤ 5 years of age). The mean age of participants in the intervention group was 15.74±2.26 months, while in the control group the mean age of participant was 30.76±14.23 months. There was no significant difference in age between the study groups (t = 0.362, df = 181, p = 0.718). The figure below shows the summary of the result

Figure 2: Mean and Standard deviation of Participants Age

35.00 30.76

30.00

25.00 Intervention 20.00 15.74 14.228 Control 15.00

10.00 Age Age ofParticipants 2.255 5.00

.00 Mean Std. Deviation

4.1.2 Gender

Over all, there were 77 (42.3%) males and 105 (57.7%) females in the study. In the intervention group, 41 (52.4%) were males and 50 (47.6%) were females, while in the control group, 36 (46.8%) were males while 55 (52.4%) were females. There was no statistically significant difference in the proportion of gender between the treatment arms (훘2 = 0.56, p =

0.45). Table 1 below shows the summary of the results.

4.1.3 Religion

The results shows that 83 (45.6%) of the total respondents were of the Christian faith and majority 99 (54.4%) of the respondent were of Islamic religion. Across the treatment groups,

40 (48.2%) were Christians in the intervention group and 51 (51.5%) of the participants belong to the Islamic faith; while in the control group, 43 (51.8%) were Christians and 48

(48.5%) of the participants were Muslims. There was no significant difference in the proportion of Christians and Muslims in the study groups (훘2 = 0.199, p = 0.665). The table 1 below shows the summary of the results.

4.1.4 Educational Level

Data on the education level of parents/guardians of participants revealed that for mothers, overall; 6 (3.3%) had only primary education, the majority 110 (60.4%) of the mothers had only secondary education while 66 (36.3%) of the mothers had tertiary education. There was a statistical significant difference in the proportion of level of education among mothers/guardians (훘2 = 6.206, p= 0.045). Among the fathers, overall, 6 (3.3%) had only primary education. And 88 (48.35%) had only secondary education and 88 (48.4%) also had tertiary education. There was no significant difference in the proportion of level of education among the fathers. (훘2 = 2.848, 9 = 0.241). The table 1 below shows the summary of the results.

Table 1: Socio-Demographic Characteristics of Participants

Overall Total Study group 훘2 p - value Socio-Demographic (Intervention=91) (Control=91) Characteristics f % f % f % Sex Male 77 42.3 41 53.3 36 46.8 0.56 0.45

Female 105 57.7 50 47.6 55 52.4

Religion Christianity 83 45.6 40 48.2 43 51.8 0.199 0.665

Islam 99 54.4 51 51.5 48 48.5

Mother's/Guardian Primary 6 3.3 6 100.00 0 0.00 6.206 0.045 educational level

Secondary 110 60.4 53 48.18 57 51.8

Tertiary 66 36.3 32 48.48 34 51.5

Father's Primary 6 3.3 5 83.33 1 16.7 2.848 0.241 educational level

Secondary 88 48.5 44 50.00 44 50.0

Tertiary 88 48.4 42 47.73 46 52.3

4.2 CLINICAL HISTORY OF PARTICIPANTS

Clinical History of participants (Baseline)

Table 2 shows the clinical history of participants in the groups at baseline. At baseline there was no case of fever recorded for participants. Furthermore, none of the children were ill.

Regarding the use of mosquito nets, overall, 64 (35.2%) did not use mosquito net, and

118(64.8%) used mosquito net; there was no significant difference in the proportion of participants that use mosquito net between the study groups (훘2 = 2.249, p = 0.134). The result showed that 127 (69.8%) of the study participants were not treated for malaria within the last month while 55 (30.2%) of the participants had been treated for malaria within the last month. Furthermore, there was no difference in the proportion of the participants that have received treatment for malaria within the last month and those that had not (훘2 = 3.862, p = 0.126).131 (71.9%) of the participants that had been treated with FansidarR or Septrin in the past had never reacted to the drug, 12 (6.6%) had reacted to FansidarR or Septrin, and 39

(21.4%) of the participant were not sure if they had reacted to FansidarR or Septrin. There were no difference in the proportion of participant that had reacted to Fansida or Septrin (훘2 =

4.969, p = 0.061)

Table 2: History of Study Participants at Baseline.

Overall Total Study group Chi- p - value square History of Study Intervention Control Participants

f % f % f % History of fever at presentation No 182 100.00 91 50.0 91 50.0 - - Yes 0 0.00 0 0.0 0 0.0 History of any other symptoms No 182 100.00 91 50.0 91 50.0 - -

Yes 0 0.0 0 0.0 0 0.0 Use of ITN No 64 35.2 27 42.2 37 57.8 2.25 0.13

Yes 118 64.8 63 53.4 54 45.8 Malaria treatment within the No 127 69.8 83 65.4 44 34.6 3.86 0.126 last 4 weeks. Yes 55 30.2 8 14.5 47 85.5

Past history of reaction to No 131 71.9 72 54.9 59 45.0 4.97 0.061 fansidar or septrin Yes 12 6.6 3 25.0 9 75.0 Don't 38 20.8 15 39.5 23 60.5 know

4.3 GENERAL EXAMINATION

General examination of participants at baseline revealed that there were no pallor, jaundice, dehydration, cyanosis and pedal oedema.

4.3.1 Anthropometry of Participants (baseline)

Length: The overall mean (SD) of length of participants was 86.1±13.5cm across the study groups. The mean (SD) of length of participants in the intervention group was 85.7±9.3cm and the mean (SD) of length of participants in the Control group was 86.4±17.7cm. There was no significant mean difference between the study groups (t = -0.307, df = 180, p =

0.760).

Weight: The overall mean (SD) weight for participants at baseline was 10.4±3.8kg. While across study groups, the mean (SD) was 9.9±1.78kg and 10.9±5.0kg for the Intervention and

Control groups respectively. There was no statistical significant difference in the mean weight of participants in the study groups (t = 1.733, df = 181, p = 0.085).

Table 3: Anthropometry of Participants (Baseline)

Intervention (n = 91) Control (n =91) t = test p - value Mean ± SD Mean ± SD Length (cm) 85.8±9.3 86.4±17.7 -0.307 0.760

Weight (kg) 9.9±1.8 10.9±5.0 1.733 0.085

Temperature (Baseline)

The overall mean and standard deviation of the axillary temperature for participants was

36.5±0.5oC. The mean and SD of participants in the intervention and control groups was

36.5±0.5oC and 36.5±0.5oC respectively. There was no significant difference in the body temperature between the treatment arms at baseline (t = 0.936, df = 180, p – value = 0.35)

Packed Cell Volume

The overall mean Packed Cell Volume (PCV) for participants was 34±2 (%). The mean packed cell volume for the intervention group was 34±2 (%) and the mean for participants in the control group was 35±2 (%). There was no statistical significant difference in PCV between the treatment arms at baseline (t = 0.93, df = 180, p-value = 0.403)

Parasite Count

The overall mean parasite count for participants (n = 182) in the study group was 67.9±80.2; while across treatment arms, the total mean parasite count was 65.8±36.35 for intervention arm, and 70.2±107.8 for the control group. There was no difference in parasite count at baseline between the treatment arms (t = 0.368, df = 180, p-value 0.713).

Table 4: Clinical Parameters of Participants at baseline

Intervention (n = 91) Control (n =91) t = test p - value Mean ± SD Mean ± SD Temperature (OC) 36.5±0.5 36.5±0.4 0.936 0.35

Packed Cell Volume 34±2.0 35±2.1 0.93 0.403

Parasite Count 65.8±36.4 70.2±107.8 0.368 0.713

4.3.2 Follow-Up Anthropometry Data of Study Participants

Table 5: Effect of IPTc using S-P on Mean length of Study participants

The study revealed that the mean Length of participants at baseline was 85.8±9.3cm for the intervention and 86.4±17.7 for the control. There was no statistical significant mean different between the study groups (t = -0.307, df = 180, p = 0.760).

At the second visit, the mean length of participants was 86.1±9.2 for the intervention and

84.7±21.0cm for the control. There was no statistical significant mean different in length of participants across study groups (t = 0.573, df = 180, p = 0.568).

At the third (3rd visit) the study revealed that the mean±sd length of participants was

86.3±9.3cm for the intervention and 84.9±21.0cm for the control. There was no significance mean difference in length of participants across groups (t = 0.554, df = 180, p = 0.580)

At the 4th visit, the study revealed that the mean±sd of length of participants was

86.33±9.30cm for the intervention and 87.0±17.8cm for the control. There was no statistical significant difference in length of participants across the study groups (t = -0.336, df = 180, p

= 0.737)

Table 5: Effect of IPTc using S-P on Mean length of participants

Intervention (n = 91) Control (n = 91) t p Mean±SD Mean±SD Length (Baseline) 85.8±9.3 86.4±17.7 -0.307 0.760

Length (2nd visit) 86.1±9.2 84.7±21.0 0.573 0.568

Length (3rd visit) 86.3±9.3 84.9±21.0 0.554 0.580

Length (4th visit) 86.3±9.3 87.0±17.8 -0.336 0.737

4.3.3 Effect of IPTc using S-P on Mean weight of participants

The study revealed that at baseline, the mean weight of participants was 9.9±1.8kg for intervention and 10.8±5.0kg for the control. There was no significant difference in mean weight of participants across study groups (t= 1.733, df = 180, p = 0.085).

The study revealed that at second visit, the mean weight of participants was 9.8±1.9kg for the

Intervention and 12.5±6.0kg for the participants in control group. There was a significant difference in the mean weight of participants across study groups (t = -4.04, df = 180, p =

0.000)

At 3rd visit, the study revealed that the mean weight of participants was 10.2±1.8kg for the intervention and 13.5±6.3kg for the control. There was a significant difference in the mean weights of participants across study groups (t= -4.86, df = 180, 0.000)

The study revealed that at 4th visit the mean weight of participants was 10.9±3.2kg for the intervention group and 14.7±6.5kg for the control groups. There was a statistical difference in the mean weight of participants across study group (t = -5.01, df = 180, p = 0.000)

Table 6: Effect of S-P on Mean weight of participants

Intervention (n = 91) Control (n = 91) t p Mean±SD Mean±SD Weight (Baseline) 9.9±1.8 10.9±5.0 1.733 0.085

Weight (2nd visit) 9.8±1.9 12.5±6.0 -4.04 0.000

Weight (3rd visit) 10.2±1.9 13.5±6.3 -4.86 0.000

Weight (4th visit) 10.9±3.2 14.7±6.5 -5.01 0.000

4.3.4 Effect of IPTc using S-P on mean Head Circumference of participants

The result revealed that the Mean Head Circumference of participants at baseline was

45.0±0.0 for Intervention and 45.0±0.0 for control. There was a statistical significant difference in the mean head circumference of participants across study groups (t = 2.48, df =

180, p = 0.014). At second visit, it was discovered that the mean head circumference of participants was 44.81±1.99 for the participants in the Intervention group and 44.7±3.2 for participants in the control group. There was no statistical mean difference in head circumference of participants (t = 0.232, df = 180, p = 0.817). The study further revealed that at the 3rd visit, it was discovered that the mean head circumference of participants was

44.9±0.9 for participants in the Intervention group and 44.83±2.1 for participants in the

Control group. There was no statistical significant mean difference in head circumference across study groups (t = 0.37, df = 180, p = 0.710). At the 4th visit, it was discovered that the mean head circumference of participants was 45.0±1.6 for the participants in the intervention group and 44.9±0.6 for participants in the Control group. There was no statistical significant mean difference in Head circumference of participants across study groups (t = 0.418, df =

180, p = 0.676)

Table 7: Effect of IPTc using S-P on mean Head Circumference of participants

Study group Intervention (n = 91) Control (n = 91) t p

Head circumference (Baseline) 45.0±0.0 45.0±0.0 2.480 0.014

Head circumference (2nd visit) 44.8±1.9 44.7±3.2 0.232 0.817

Head circumference (3rd visit) 44.9±0.9 44.8±2.1 0.373 0.710

Head circumference (4th visit) 45.0±1.6 44.9±0.6 0.418 0.676

4.4 EFFECT OF IPTc USING S-P ON THE MEAN AXILLARY TEMPERATURE IN CHILDREN LESS THAN FIVE (5) YEARS OF AGE 4.4.1 Overall Mean Axillary Temperature of Participants across Follow-up Periods

Figure 2 shows the overall mean (SD) at base line as 36.5±0.5OC; and the second visit, the overall mean (SD) was 36.9±0.8OC, while at the third visit the mean (SD) temperature of the study participants was 36.9±0.7OC. The figure shows that at the forth visit the mean axillary temperature was 37.4±1.1OC.

Figure 3: Overall Mean Axillary Temperature of Participants across Follow-up Period

37.60 37.40 37.41 37.20 37.00 36.97 36.80 36.86 36.60 36.51 36.40

Axillary Axillary Temperature(OC) 36.20 36.00 Baseline 2nd visit 3rd visit 4th visit Follw-up period

4.4.2 Mean Axillary Temperature of Participants

Table 8 shows the mean axillary temperature of the study participants. Result s revealed that the baseline mean temperature for the Intervention group was 36.5±0.5OC, and the mean (SD) temperature baseline for the control group was 36.5±0.5OC. There was no statistical significant mean difference in the temperature between the study group at baseline (t = 0.936, df = 180, p = 0.35). At the second visit, the mean (SD) temperature was 36.9±0.5OCand

37.2±0.8OC for the Intervention and control group respectively; there was a significant mean difference in the study groups (t = 2.09, df = 180, p = 0.038). The result showed that at the 3rd visit, the mean temperature was 36.8±0.5OC for the intervention group and 37.2±0.8OC for the control group. There was a significant mean difference in the temperature between the study groups with the control group having higher mean temperature than participants in the control group. (t = 4.007, df = 180, p = 0.0005). At the 4th visit, the mean temperature for the intervention group was 36.9±0.5OC and the mean temperature for the control group was

38.0±1.1OC. There was a significant mean difference in the temperature between the study groups with the control group having a higher mean temperature than the intervention group

(t = 9.89, df = 180, p = 0.0005).

Table 8: Mean axillary temperature of participants Intervention (n = 91) Control (n =91) t = test p - value Mean ± SD Mean ± SD Axillary Temperature 36.5±0.5 36.5±0.5 0.936 0.35 (OC) Baseline Axillary Temperature 36.7±0.6 36.9±0.9 2.09 0.038 (OC) (2nd Visit) Axillary Temperature 36.8±0.5 37.16±0.8 4.007 0.0005 (OC) (3rd Visit) Axillary Temperature 36.8±0.5 38.03±1.1 9.9 0.0005 (OC) (4th Visit)

4.5 EFFECT OF IPTC USING S-P ON THE INCIDENCE OF CLINICAL MALARIA IN CHILDREN LESS THAN FIVE YEARS OF AGE

Result in table 9 shows the effect of IPTc using S-P on the incidence of Clinical malaria in children under five years of age. At the 2nd visit, an overall 161 (88.5%) of the participants had no fever, while 21 (11.5%) had fever plus malaria parasite count (PC). Across the study groups 5(23.8%) had fever plus parasite count in the intervention group while 16 (76.2%) had fever plus parasite count in the control group. There was a significant difference in the

97 proportion of fever plus parasite count between the study group with less number of participants having fever plus parasite count in the Intervention group (훘2 = 6.513, p = 0.011).

At the 3rd visit, a total 154 (84.6%) of the overall participant did not have fever, while 28

(15.4%) had fever plus parasite count. Result further indicated that across the study groups 8

(28.6%) had fever plus parasite count in the intervention group compared to 20 (71.4%) with fever plus parasite count in the control group. There was a significant difference in the proportion of participants with fever plus parasite count at the 3rd visit across the study groups (훘2 = 6.078, p = 0.014). At the 4th visit, a total of 154 (84.6%) did not have fever, while 28 (15.4%) had fever plus parasite count. Across the study groups, 3 (10.7%) had fever plus parasite count in the Intervention group, while 25 (89.3%) had fever plus parasite count in the control group. There was a significance difference in the proportion of participants with fever plus parasite count across the study group, with more participants in the control group having symptom of fever plus parasite count than the participants in the intervention group (훘2 =20.429, p = 0.000).

Table 9: Effect of S-P on the Incidence of Clinical Malaria in Children Less than Five years of Age

Overall Total Study group Chi- p - square value Intervention Control

f % f % f %

Fever +PC (2nd visit) No 161 88.5 86 53.4 75 46.6 6.513 0.011

Yes 21 11.5 5 23.8 16 79.2

Fever+PC (3rd visit) No 154 84.6 83 53.9 71 46.1 6.078 0.014

Yes 28 15.4 8 28.6 20 71.4

Fever+PC (4th visit) No 154 84.6 88 57.1 66 42.9 20.429 0.000

Yes 28 15.4 3 10.7 25 89.3

4.5.1 Effect IPTc Using S-P on the Time to Event to Develop Clinical Malaria.

The Kaplan Meier test was used to compare the time it takes for fever (clinical malaria) to occur among participants in the study groups. The time of visit was measured in time intervals of 28 days in between visits. The Kaplan Meier chart (Figure 3) shows that participants in the intervention group (S-P use) had significant lower probability of having clinical malaria than the control group within the earlier time of the study (Breslow test: χ2 =

5.130, df = 1, p = 0.024). Also, around the time between the 2nd and the 3rd visit, the results revealed that participants in the control group had a significantly higher probability of having clinical malaria than participants in the intervention group (Tarone-Ware: χ2 = 4.844, df = 1, p =0.028). At the end of the time frame (28 days), the result shows that the study groups differed in the time it took her to develop clinical malaria. The Mantel Cox test revealed that the control group had a higher probability of developing clinical malaria than the intervention group (χ2 = 4.385, df = 1, p = 0.036).

Table 10: Test of Equality of Time to Event of Clinical Malaria for the Study Groups

Chi-Square (χ2) df P –value

Log Rank (Mantel-Cox) 4.385 1 .036

Breslow (Generalized Wilcoxon 5.130 1 .024

Tarone-Ware 4.844 1 .028

Figure 4: Kaplan Meier Curve for Clinical Malaria between Study Groups

1.0

Study group 0.8 Intervention Control Cum Survival

0.6

0.4

0.2

0.0

20.0 40.0 60.0 80.0 Time in days

4.6 EFFECT OF IPTc USING S-P ON INCIDENCE OF ANAEMIA IN UNDER-FIVES

4.6.1 Mean Packed Cell Volume (PCV) of Participants

Results in Table 11 shows that the Mean±SD PCV of participants across the study group at baseline was 34±2(%) for intervention group and 35±2(%) for control group; there was a significant difference between the groups (t = 2.231, df = 180, p = 0.027). At the 2nd visit, the

Mean±SD PCV for the intervention group was 35±2(%) and 33±4(%) for the control group.

There was a significant difference between groups (t = 3.073, df = 180, p = 0.002). At the 3rd

100 visit, the result revealed that the Mean ±SD PCV for the Intervention was 36±1(%) and 31±6 for the control group. There was a statistical significance difference between groups with participants in the intervention group having higher mean PCV than the participants in the control group (t = 8.37, df = 180, p = 0.0005). At the 4th visit, the mean and standard deviation of participants PCV in the Intervention group was 37.±1(%), and 28±6(%) for the control group. There was a significance mean difference in PCV across the groups (t = 14.81, df= 180, p = 0.0005).

Table 11: Mean Packed Cell Volume of Participants Intervention (n = 91) Control (n =91) t = test p - value Mean ± SD Mean ± SD Packed Cell Volume (%) 34±2 35±2 2.23 0.027 Baseline Packed Cell Volume (%) 35±2 33±4 3.073 0.002 (2nd visit) Packed Cell Volume (%) 36.±1 31±6 8.374 0.0005 (3rd visit) Packed Cell Volume (%) 37±1 28±6 14.819 0.0005 (4th visit)

4.6.2 Line Trend for Packed Cell Volume across study group

Figure 4 shows the trend of the overall (N = 182) PCV of participants in the study groups.

The figure revealed that at baseline, the mean PCV for the control group was 35%and there was a slight decrease of the PCV at the 2nd visit (33%). Furthermore, the mean PCV decreased at the 3rd and 4th visits (31% and 27.74% respectively). For the Intervention group, the mean PCV at baseline was 34% and at 2nd visit, the PCV increased to 35% and further increased to 36% and 37% at 3rd and 4th visits respectively. The figure clearly shows a steady increase of mean PCV for the Intervention group and a simultaneous decrease of PCV for the participants in the control group.

101

Figure 5: Line Trend for Packed Cell Volume across Study Groups

40.00 36.27 33.93 34.80 37.32 35.00 34.63 30.00 33.35 30.85 27.74 25.00 20.00 Intervention 15.00 10.00 Control

PackedVolume cell (%) 5.00 .00 Baseline 2nd visit 3rd visit 4rd visit Follow-up period

4.6.3 Effect of IPTc using S-P on Anaemia in Study Participants

The results in table 12 shows that at 2nd visit, overall 167 (91.8%) of the study participants were not anaemic, while 15 (8.2%) were anaemic (PCV <30%). Across the study group; 3

(3.3%) of the participants in the intervention group were anaemic (Blood count <30%) and 12

(13.2%) of the participants in the control group were anaemic (PCV<30%). There was a significant statistical difference in proportion of participants with PCV <30% between the study groups with participants in the control group having more cases of anaemia than participants in the intervention group (훘2 = 5.885, p = 0.015). At the 3rd visit, result further revealed that overall 169 (92.9%) of the participants had PCV≥30% (Normal) while 13

(7.1%) of the participants had PCV < 30% (anaemic). Across the groups, no participant (0%) in the intervention group was anaemic while 13 (14.3%) of the participants in the control group were anaemic. There was a statistical significance difference in the proportion of participants that were anaemic between the study groups; with all those that are fall under the control group. (훘2 = 14.00, p = 0.0005). Result of the 4th visit by participants revealed that the

102 overall, 151 (83.0%) were not anaemic (PCV≥30%), while 31 (17.0%) of the participant had

PCV < 30% (anaemic). Across the groups, there was no case of anaemia in the intervention group, while 31 (34.10%) of the participants in the control group had PCV <30% (anaemic).

There was a significant difference in the number of anaemic cases across the study group (훘2

= 37.364, p = 0.0005).

Table 12: Effect of IPTc using S-P on Anaemia in Study Participants

Overall Total Study group Chi- p - square value Control Intervention f % f % f %

Anaemia (2nd visit) No 167 91.8 88 96.7 79 86.8 5.885 0.015

Yes 15 8.2 3 3.3 12 13.2

Anaemia (3rd visit) No 169 92.9 91 100 78 85.7 14 0.0005

Yes 13 7.1 0 0 13 14.3

Anaemia (4th visit) No 151 83.0 91 100 60 65.9 37.364 0.0005

Yes 31 17.0 0 0 31 34.1

4.6.4 Incidence of Anaemia based on Grading in study groups

Table 13 shows the incidence of anaemia based on grading in study groups across follow-up periods. PCV ≤ 30% is mild anaemia, PCV ≤ 24% is moderate anaemia, and PCV≤ 15% is severe anaemia. The table revealed that at baseline within the intervention group 91 (100%) of the participants had normal PCV and 91 (100%) of the participants in the control had normal PCV. At second visit no participant in the intervention group had severe anaemia, one

103

(1.1%) had moderate anaemia, while two (2.2%) had mild anaemia. In the control group one

(1.1%) of the participant in had severe anaemia, while 17 (18.1%) had mild anaemia. There was a statistical significant difference in the proportion of anaemia between the study groups at the second visit (훘2 = 15.24, p = 0.002).

At the 3rd visit, 139 (76.4%) of the participants had normal PCV; two (2.2%) of the participants in the control group had severe anaemia, eight participants (8.8%) had moderate anaemia while 33 participants (36.3%) had mild anaemia. There was a statistical significance difference in proportion of anaemia between the study groups at the 3rd visit (훘2 = 56.302, p =

0.0005). At the 4th visits, the overall, 115 (63.2%) of the participants had normal PCV. Ninety one (100%) participants in the intervention group had normal PCV.In the control group, one

(1.1%) of the participant had severe anaemia, 23 (25.3%) had moderate anaemia and 43

(47.3%) had mild anaemia. There was a significant difference in the proportion of anaemia across study groups (훘2= 106.035, p = 0.0005)

Table 13: Incidence of Anaemia based on grading in study groups across follow up period

Anaemia Chi- P- Study group Total square value Intervention n(%) Control n(%) Anaemia (Baseline) Normal 91(100.0) 91(100.0) 182(100.0) - - Mild 0(0.00) 0(0.00) 0(0.00) Moderate 0(0.00) 0(0.00) 0(0.00) Severe 0(0.00) 0(0.00) 0(0.00) Anaemia ( Second visit) Normal 88(96.7) 73(80.2) 161(88.25) 15.24 0.002 Mild 2(2.2) 17(18.7) 19(10.4) Moderate 1(1.1) 0(0.00) 1(0.5) Severe 0(0.00) 1(1.1) 1(0.5) Anaemia ( Third visit) Normal 91(100.0) 48(52.7) 139(76.4) 56.302 0.000 5 Mild 0(0.00) 33(36.3) 33(18.1) Moderate 0(0.00) 8(8.8) 8(4.4) Severe 0(0.00) 2(2.2) 2(1.1)

104

Anaemia ( Fourth visit) Normal 91(100.0) 24(26.4) 115(63.2) 106.035 0.000 5 Mild 0(0.00) 43(47.3) 43(23.) Moderate 0(0.00) 23(25.3) 23(12.6) Severe 0(0.00) 1(1.1) 1(0.5)

4.7 EFFECT OF S-P AS IPTc ON THE INCIDENCE OF SEVERE MALARIA IN UNDER-FIVES 4.7.1 Mean Parasite Counts of Participants across Study Group

Table 14 shows the mean parasite count for participants across the study group. The table revealed that at baseline the mean±SD for the intervention group was 65±36.4/ (ul) and

70.2±707.8/ (ul) for the control group. There was no significant mean difference in parasite count across group (t = 0.368, df = 180, p = 0.713). At the second visit, the mean±SD parasite count was 10.5±48.6/ (ul) and 26.0±105.4/ (ul) for intervention and control group respectively. There was no significant difference in parasite count across group (t = 1.275, df

= 180, p = 0.204). At the third visit, the mean±SD parasite count was 6.23±14.52/ (ul) and

34.64±36.94/ul for intervention and control respectively. There was a statistical significant difference in parasite count across group (t = 6.822, df = 180, p = 0.0005). At the fourth visit, the result revealed that the mean±SD parasite count was 0.07±0.629/ (ul) and 118.23±169.53/

(ul) for intervention and control respectively. There was a significant difference in the parasite count between intervention and control group (t = 6.649, df = 180, p = 0.0005)

Table 14: Mean Parasite Count of Participants

Intervention (n = 91) Control (n =91) t = test p - value Mean ± SD Mean ± SD Parasite count (Baseline) 65.8±36.4 70.2±107.8 0.368 0.713

Parasite count (2nd visit) 10.5±48.6 26.0±105.4 1.275 0.204

Parasite count (3rd visit) 6.2+14.5 34.6±36.9 6.822 0.0005

Parasite count (4th visit) 0.07±0.6 118.2±169.5 6.649 0.0005

105

4.7.2 Parasite Density

The overall mean parasite density/ (ul) at baseline was 2718.46±3208.45, for second visit, the overall mean was 730.11±3288.62/ (ul) while the third and 4th had mean±SD of

816.92±1255.91/(ul) and 2365.92±5336.87/ (ul) respectively. Across the group, the mean parasite density for the intervention group at baseline was 2630.77±1453.91 and

2806.15±4310.27 for the control group. At the second visit the mean±SD for intervention and control group were 419.78±1941.82/ (ul) and 1040.44±4217.19/ (ul) for the intervention and control respectively. At the 3rd visit, the mean±SD parasite density for the intervention and control was 249.23±580.82/ (ul) and 1384.62±1477.52/ (ul) respectively. At the 4th visit, the parasite density for intervention and control was 2.64±25.16/ (ul) and 4729.23±6781.28/ (ul) respectively. The result shows there was a decrease parasite density across the follow-up in the intervention group and an increase of parasite density across the follow-up period for the control group.

Figure 6: Line graph showing Parasite Density across Study Group

5000.00 4729.23 4500.00 4000.00 3500.00 3000.00 2806.15 2500.00 2630.77 Intervention 2000.00 Control 1500.00 1384.62 Parasite density(ul) 1000.00 1040.44 500.00 249.23 419.78 2.64 .00 Baseline 2nd visit 3rd visit 4th visit Follow-up Period

4.7.3 Effect of IPTc using S-P on the Incidence of Severe Malaria

106

The Incidence of Severe Malaria across Study Group

Table 15 shows that the incidence of severe malaria (Parasite count ≥250000 ul) in both study. At baselines, there was no subject with parasite count ≥250,000 in both groups. At the second visit 1 (50%) case of severe malaria was found in the intervention group while one(50%) case of severe malaria was also seen in the control group. At the 3rd visit, one(33.3%) case of severe malaria was found in the intervention group while 2 cases (66.7%) were found in the control group. At the 4th visit, no case of severe malaria was found in the intervention group while 4 cases (100.0%) were found in the control group.

Table 15: Effect of IPTc using S-P on Severe Malaria across study groups (using parasite count) Overall Study group Chi-square P-value Parasite count Intervention Control

F % F % F %

Parasite <250000 180 98.9 90 50.0 90 50.0 0.000 1.000 count 2nd ≥250000 2 1.1 1 50.0 1 50.0 visit

Parasite <250000 179 98.4 90 50.3 89 49.7 0.339 0.560 count 3rd ≥250000 3 1.7 1 33.3 2 66.7 visit

Parasite <250000 178 97.8 91 51.1 87 48.9 4.090 0.043 count 4th ≥250000 4 2.2 0 0.0 4 100.0 visit

107

Table 16: PROTECTIVE EFFICACY OF MALARIA, ANAEMIA AND SEVERE MALARIA

Incidence of clinical malaria * study group cross-tabulation

STUDY GROUP TOTAL Intervention Control Incidence of Malaria 16 61 77 Clinical malaria No Malaria 75 30 105 TOTAL 91 91 182

Incidence of Malaria in Intervention Group = 16/91= 0.176

Incidence of Malaria in Control Group = 61/91 = 0.670

Incidence Rate Ratio (IRR) = Incidence in Intervention/Incidence in Control

IRR = 0.176/0.670 = 0.262

Protective Efficacy (PE) =( 1 – IRR) = 1- 0.262= 0.737= 74%

Incidence of anaemia * study group cross-tabulation

STUDY GROUP TOTAL

Intervention Control

Incidence of Anaemia 3 56 59 Anaemia No Anaemia 88 35 123

TOTAL 91 91 182

108

Incidence of Anaemia in the Intervention Group = 3/91 = 0.033

Incidence of Anaemia in the Control Group = 56/91 = 0.615

Incidence Rate Ratio (IRR) = Incidence in Intervention/Incidence in Control

IRR = 0.033/0.615 = 0.054

Protective Efficacy (PE) = (1- IRR) = 1 – 0.054= 0.946 = 95%

Incidence of severe malaria * study group cross-tabulation

STUDY GROUP TOTAL Intervention Control Incidence of Severe Malaria 2 7 9 Severe malaria No Severe 89 84 173 Malaria TOTAL 91 91 182

Incidence of Severe Malaria in Intervention Group = 2/91= 0.022

Incidence of Severe Malaria in Control Group = 7/91 = 0.077

Incidence Rate Ratio (IRR) = Incidence in Intervention/Incidence in Control

IRR = 0.022/0.077 = 0.286

Protective Efficacy (PE) = (1 – IRR) = 1- 0.286 = 0.714 = 71%

109

CHAPTER FIVE

5.0 DISCUSSION

This study set out to investigate the effect of Seasonal intermittent preventive treatment using

S-P on the incidence of clinical malaria, anaemia, and severe malaria in children between 1-

5years of age in the under-five clinic at the Seventh-Day Adventist Hospital, Jengre, Plateau

State to determine if there was any protective efficacy on clinical malaria, anaemia and severe malaria so as to formulate a treatment guideline to be adopted in my centre.

SOCIO-DEMOGRAPHIC STATUS

Age

There was no significant mean age difference between study groups at base line. This was similar to a study carried out by Dicko Alassane et al134 in Mali. The similarities could be as a result of the fact that both studies were carried out in a rural area, amongst under fives and were randomised control studies.

Gender

There was no significant difference in the proportion of gender between study groups at base line. This was similar to a study carried out by Dicko Alassane et al134in Mali.The similaries could be as a result that both studies were carried out in a rural setting and among children less than five years who were still dependent on their parents for up keep unlike most adolescent who migrate to the urban cities for survival.

Religion and Educational Level of Care Givers

There were no significant differences in proportion of the religion and level of education of care givers between study groups at base line. This could be because the study area is a commercial area comprising of people of mixed religious faith and also because of randomization.

110

CLINICAL DATA

Anthroponometric

There were no significant differences between study groups with regards to their

Anthroponometric measurements. This was similar to a study carried out by Kweku et al in

Ghana133 and Dicko Alassane et al134 in Mali. The similarities could be as a result of the study participants were of similar age groups, and the study designs were similar. Also the similarities might be because the studies were carried out in a rural setting.

Temperature

There was no significant difference in body temperature between the study groups at base line. This was similar to a study carried out by Dicko Alassane et al134.This might be as a result of the randomization done in both studies and also because participants with high temperature were not recruited at baseline.

USE OF INSECTICIDE TREATED NET

There was no significant difference in the use of insecticide treated nets between study groups at base line. This was similar to a study carried out by Kweku et al133 and Dicko

Alassane et al134.This could be as a result of randomization or by chance. The use of ITN in the study was about 64.8%.The result was higher than that seen in Kweku et al in Ghana133,

Dicko et al in Mali139 and Cisse et al in Senegal140. This was because in the three study sites,nets were usually in a bad condition or untreated. However, the result obtained in my study was relatively lower than that seen in Konate et al16 and Dicko et al134.The reason was that all the study participants in the two studies received ITN on entry into the study.The result obtained in my study was slightly similar to that seen in Bojan et al141. This could be as

111 a result of the fact that both studies were randomised, carried out in a rural setting or by chance.

EFFECT OF IPTc USING S-P ON INCIDENCE OF ANAEMIA, UNCOMPLICATED

MALARIA AND SEVERE MALARIA

This study has shown that three doses of IPTc with SP given at monthly intervals during the peak transmission season reduced the incidence of Anaemia, uncomplicated and severe malaria.

Effect of IPTc using S-P on the Incidence of Uncomplicated Malaria

The study revealed that the incidence of malaria was reduced in the intervention arm compared to the control arm with a protective efficacy (PE) of 74%.This result was consistent to findings reported by Kweku et al in Ghana133( For bimonthly SP,PE=24%), Dicko et al in mali134(PE=82%), Cisse et al in Senegal140 (PE=86%), Meremikwu et al14(PE=74%) ,Konate et al16 (PE=71%) and Bojang et al (93%)141.The similarities could be as a result of the study participants being all under five years. The study areas were all in West Africa especially in the rural areas and the studies were all randomised controlled trials. The duration of the study was four months which was similar to the duration of study conducted by Dicko et al in

Mali134 and Cisse et al in Senegal140 but different from that conducted by Kweku et al in

Ghana133 which was six months. The difference in the duration of the study was due to the time stipulated for the training programme.

The level of protective efficacy in my study was higher (PE=74%) than that seen in Kweku et al133 (PE=31%) and Konate et al16 (PE=71%), the difference in protective efficacy between my study and Kweku et al might be because my study was carried out in the hospital and the sample size was small compared to Kweku et al133 that had larger sample size and was carried out in a community which made supervision much difficult. Also the sampling method used

112 in my study was simple random while that used by Kweku et al133 was cluster random sampling. The difference in sampling methods might have contributed to the different results.

The proportion of participants that slept under ITN in my study (64%) was higher than that in

Kweku et al133(11%).This also might have contributed to the difference in result since ITN offers an added protective effect against malaria.In the study conducted by Kweku et al133, S-

P was administered bimonthly compared to my study where SP was administered monthly.

The difference in the rate of administration might have also contributed to the difference in protective efficacy since the monthly administration will increase the concentration of the drug compared to the bimonthly and hence greater protective efficacy.

The difference in the level of protective efficacy between my study( PE=74%) and Konate et al16 (PE=71%) might be due to the different sampling method, the difference in sample size or by chance. Konate et al16 did a double blinded study while mine was not blinded. Blinding would have removed a lot of bias compared to un-blinded study. The difference in drug formulation might have contributed to the difference in the result seen. Konate et al16 used

SP+AQ which are two different drugs while only SP which is a fixed drug formulation was used in my study. Fixed drug formulation is usually easy, less cumbersome to administer, provides better compliance and gives better outcome than two different drug formulations.

The protective efficacy seen in study carried out by Bojang et al141 (PE=93%), Dicko et al134(

PE=82%) and Cisse et al140 (PE= 86%) was higher than that seen in my study (74%). In the study carried out by Bojang et al141 and Dicko et al134, the study participants were all given

ITN upon enrolment into the study which might have added to the beneficial effect of IPTc and thus increased protective efficacy. Also the difference in the level of protective efficacy between my study (PE=74%) and Cisse et al140 (PE=86%),Dicko et al134 (PE=82%) and

Bojang et al141 (PE=93%) might be as a result of the different drugs used in administering

IPTc. Single drug (SP) was used in my study while combination therapy was used in the

113 above three mentioned studies ( Cisse et al = SP+AS, Dicko et al =SP+AQ,and Bojan et al=

SP+AQ). Combination therapies are more efficacious than single therapy and thus better protective efficacy.

The overall outcomes in all the studies carried out were that IPTc was highly effective for the prevention of malaria in children under five years of age living in areas where there is high seasonal malaria transmission.

A Cochrane review by Meremikwu et al 14revealed that giving antimalarial drugs to preschool children as IPTc during the malaria transmission season markedly reduced episodes of clinical malaria (PE=74%) and severe malaria (PE=73%) even in areas where insecticide treated net usage was high.14 The Protective efficacy (74%) was similar to that seen in my study(74%).The similarities might be because both studies were carried out in the under- fives, West African sub-region and in rural setting. It could also be by chance.

A systematic review and meta-analysis on the efficacy and safety of IPTc revealed a protective efficacy of 82% against malaria (95%CI;75%-87%) and that no serious adverse event attributed to the drugs used for IPTc were observed as was seen in my study. It also revealed that IPTc was a safe method of malaria control that has the potential to avert a significant proportion of clinical malaria episodes in areas with marked seasonal malaria transmission and also appears to have a substantial protective effect against all cause mortality due to malaria.142 The protective efficacy seen in the review (PE=82%) was higher than that seen in my study (PE=74%).The difference might be due to different methods of analysis or by chance. Although, the protective efficacy was higher than that seen in my study, the findings indicate that IPTc was a potential valuable tool that can contribute to control of malaria in areas with marked seasonal transmission.

114

The participants in the study group were given SP which was a single dose formulation. Also subjects who fell ill with malaria in the course of the study were given free curative care using ACT. A Study conducted by Pitt et al143 on the community perceptions of IPTc revealed that single dose formulations and activities such as free curative care could increase the success of IPTc implementation.143

Effect of IPTc on Anaemia

The incidence of Anaemia during the intervention period was significantly lower in the IPTc group compared to the placebo group. This was similar to the study carried out by Kweku et al133 in Ghana and Dicko et al134in Mali. The similarity in the result could be as a result of the fact that both studies were carried out in West Africa and amongst under-fives. Although the protective efficacy against anaemia in the study was 95% which higher than the protective effect against anaemia in studies carried out by Kweku et al in Ghana (PE= 31%)133 and

Dicko et al in Mali(PE=12%)134,the difference might be as a result of the larger sample size in both studies there by making supervision very difficult in both studies. Also in the study carried out by Kweku et al133 the S-P was given bimonthly while it was administered monthly in my study. The level of parasitaemia of red blood cells will be much lower in the monthly

S-P group compared to the bimonthly group, there by accounting for the higher protective effect. The level of protective effect in the study is closely related to that seen in Cisse et al(PE=86%)140,Meremikwu et al(PE=71%)14 and Systematic review and Meta-Analysis of twelve studies(84%)142.

The majority of the study participants in the control group had mild to moderate anaemia as compared to that in the intervention group. Four cases of severe anaemia were observed in the control group during the course of the study and post-intervention period. All of the participants who had severe anaemia also had severe malaria. The study shows that IPTc

115 provides substantial protection against anaemia. Although IPTc was effective in reducing episodes of anaemia detected in our study, we did not find a significant reduction in the incidence of anaemia at the end of the IPTc intervention period. This was consistent with observation with Cisse et al in Senegal140 and Kweku et al in Ghana133, and with the findings of IPTi studies in Ghana144. This could be due to the fact that the study children were closely monitored and all episodes of anaemia were promptly treated with iron plus folic acid. Also the duration of the study was short to really show any significant impact.

Effect of IPTc on Severe Malaria

The study revealed that only nine study participants had severe malaria. Seven cases of severe malaria were seen in the control arm while two cases were seen in the intervention arm. The protective efficacy (PE) was 71%.This was consistent with studies conducted by

Meremikwu et al(PE=73%)14, Dicko et al (PE=87%)134 and Konate et al(PE=69%) 16.In the study conducted by Dicko et al134, only 17 of the study participants had severe malaria. Two of the participants were in the intervention group while the remaining fifteen were in the control group. The study carried out by Meremikwu et al14 showed that IPTc prevented three quarters of all severe malaria episodes. Also, in the study conducted by Konate et al16, severe malaria was observed in thirteen children in the control group compared to four children in the intervention group.

Although, the protective efficacy in my study (PE=71%) was higher than that seen in Konate et al16 (PE=69%), the difference might be attributed to fact that my study was carried out in a hospital environment and my sample size was smaller compared to that carried out by Konate et al16 there by making supervision very feasible and better outcome. The sampling technique also might have contributed to the difference seen in the results.

116

The level of protective efficacy in my study (PE=71%) was lower than that seen in studies conducted by Meremikwu et al 14(PE=73%) and Dicko et al 134( PE=87%).The difference in protective efficacy might be due to the fact that in Dicko et al134 the study participants were given ITN at enrolment into the study which gives them an added protective effect against malaria and thus better protective efficacy. Also the different sampling technique (Cluster sampling in Meremikwu et al14 and Dicko et al134 and Simple random sampling technique in my study) might have resulted in the different level of protective efficacy seen. In my study, ages between 12 months and 59 months was recruited while the above two studies

(Meremikwu et al14 and Dicko et al134) ages between three months and 59 months were recruited. This might have contributed to the increased protective efficacies in the above two studies since children less than six months old are protected from malaria by their mother’s antibodies still present in them.

5.1 STRENGTHS OF THE STUDY

1. The Randomised controlled design prevented a number of biases in the

selection into two arms as well as in assessing outcomes.

2. IPTc can be used as a component of malaria control in areas with seasonal

malaria transmission.

3. As the international community moves towards the target of malaria

elimination, new malaria control tools like IPTc will be needed.

5.2 LIMITATIONS OF THE STUDY

1. IPTc does not have established delivery system unlike the case of IPT in

pregnant women and infants. However high coverage can be obtained using

community health workers as shown in study conducted in Ghana.133

117

2. IPTc may enhance the spread of drug resistance. Studies conducted by Dicko

et al in Mali134 revealed that IPTc have contributed to the increase in

frequency of some of resistant markers but the true impact of the resistance is

yet to be established.

3. IPTc could interfere with the development of naturally acquired immunity

raising concerns that there would be an increase period of risk (rebound

malaria) during the post intervention period. However, several years of

administration would be needed to define the degree to which acquisition of

natural immunity would be impaired. It is very unlikely that this would

outbalance the substantial gains made during the period when the drug was

given. A study by Dicko et al145 on malaria morbidity in children in the year

after they had received IPTc in mali revealed that IPTc was not associated

with an increase in incidence of malaria episodes, prevalence of malaria

infection or anaemia in the subsequent malaria transmission season.

4. Duration of evaluation was just three months; however in this region 85-90%

of clinical malaria occurs between August to November.

5. Because no active follow up was done during the intervention and post

intervention period, we cannot be sure how many children had moved out for

substantial period during the study period.

6. Subjects that had malaria in the course of the study were treated and were re-

introduced into the study which might have affected the result of the study

since the antimalaria have a protective effect against clinical malaria for at

least 28 days.

5.3 IMPLICATION OF THE STUDY TO FAMILY PHYSICIANS AND OTHER PRIMARY CARE PROVIDERS

118

Family Physicians, and other primary care providers( Paediatricians and Public health

Physicians) that render care to under-fives may include IPTc as an adjunct malaria prevention and control tool to compliment on going malaria control tool since it is safe, well tolerated and provides substantial additional protection against malaria.

5.4 RECOMMENDATION

IPTc should be used as a malaria prevention tool to compliment on going preventive efforts like ITNs and IRS in areas of highly seasonal malaria transmission.

SP is a safe, well-tolerated drug for IPTc.

High coverage of IPTc can be achieved by using community health workers.

Single formulation of drug could increase the success of IPTc.

Activities such as free curative care and ITN could increase the success of IPTc.

A double blind study over a longer duration ( at least 6 months) needs to be conducted to fully evaluate the efficacy, benefit and tolerability of IPTc.

5.5 CONCLUSIONS

IPTc given during the malaria transmission season, provided substantial additional protection against clinical malaria, infection with malaria, and anaemia to that provided by ITNs. IPTc with SP was safe and well tolerated. As the international community moves towards the target of malaria elimination, new malaria control tools will be needed. IPT in children targeting the transmission season appears to be one of the strongest available tools to achieve this goal.

119

REFERENCES

1. Nordqvist C. “What is malaria” Medical News Today.(2013,October 10).Retrieved from

http://www.medicalnewstoday.com/articles/150670. Accessed on 1/1/14.

2. WHO (2010): Guidelines for the Treatment of Malaria (Report) (2nd Ed.). Available at:

Error! Hyperlink reference not valid.. (Accessed on 12/01/2013).

3. Unicef: World Malaria Day 2013; Invest in the future: Defeat malaria. Available at

http://www.unicef.org/health/files/malaria_brochure_18April2013.pdf.(Accessed on

4/12/13).

4. Carneiro I, Roca-Feltrer A, Griffin JT, Smith L, Tanner M, Schellenberg JA, et al., et al.

Age-patterns of malaria vary with severity, transmission intensity and seasonality in

sub-Saharan Africa: a systematic review and pooled analysis. PLoS One 2010; 5: e8988-

doi: 10.1371/journal.pone.0008988 pmid: 20126547.

5. Mulligan JA, Yukich J, Hanson K. Costs and effects of the Tanzanian national voucher

scheme for insecticide-treated nets. Malar J 2008; 7: 32- doi: 10.1186/1475-2875-7-32

6. Grabowsky M, Nobiya T, Selanikio J. Sustained high coverage of insecticide-treated

bednets through combined Catch-up and Keep-up strategies. Trop Med Int Health 2007;

12: 815-22

7. 2012 malaria consortium: Intermittent Preventive Treatment. Available at

http://www.malariaconsortium.org/page.php?id=114 (Accessed on 12/01/13).

8. Brieger WR. Waiting for Intermittent preventive treatment of infant to go live. African

Health Nigeria 2012; 34 (4):15-17.

120

9. Eisele TP. Malaria prevention in pregnancy, birth weight, and neonatal mortality: a

meta-analysis of 32 national cross-sectional datasets in Africa. Lancet Infect Dis 2012;

12: 942–9.

10. Menéndez. Malaria Prevention with IPTp during pregnancy reduces neonatal mortality.

PLoS ONE 2010; 5: e9438.doi: 10. 1371/journal.pone.0009438.

11. WHO Global Malaria Programme. WHO Policy Recommendation: Seasonal Malaria

Chemoprevention (SMC) for Plasmodium falciparum malaria control highly seasonal

transmission areas of the Sahel sub-region in Africa. March 2012. Available at

http://www.who.int/malaria/areas/preventive_therapies/children/en/ .Accessed on

03/02/13

12. Cairns M, Roca-Feltrer, Tini Garske A. Estimating the potential public health impact of

seasonal malaria chemoprevention in African children. Nature Communications | 3:881 |

DOI: 10.1038/ncomms1879 | www.nature.com/naturecommunications. Accessed on

01/02/13

13. MARA/ARMA (Mapping Malaria Risk in Africa / Atlas du Risque de la Malaria en

Afrique). Maps of Malaria. July 2001. http://www.mara.org.za/. Accessed on 01/02/13

14. Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C. Intermittent preventive

treatment for malaria in children living in areas with seasonal transmission. Cochrane

Database Syst Rev 2012; 2:CD003756. doi: 10.1002/14651858. CD003756.pub4.

15. Maxmen A. Mapping identifies best targets for malaria prevention: Seasonal treatment

would save lives, but leave many behind. Nature/News 2012.Available at http://www.

nature.com/news/mapping-identifies-best-targets-for-malaria-prevention-

1.10781.(Accessed on 20/6/13)

121

16. Konaté AT, Yaro JB, Ouédraogo AZ. Intermittent Preventive Treatment of Malaria

Provides Substantial Protection against Malaria in Children Already Protected by an

Insecticide-Treated Bednet in Burkina Faso: A Randomised, Double- Blind, Placebo-

Controlled Trial. PLoS Medicine 2011; 8. e1000408

http://www. plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000408.

17. Lagos State Ministry of Health, 2013. Malaria Control Program. Available at:

http://www.lagosstateministryofhealth.com/programme_id=6 (Accessed on

12/01/2013).

18. Nigeria malaria fact sheet, United States Embassy in Nigeria. Available at:

http://photos.state.gov/libraries/nigeria/487468/pdfs/December%20malaria%20fact%20

2.pdf (Accessed on 12/01/2013).

19. Gething PW, Patil AP, Smith DL, Guerra AC, Elyazar IR, Johnston GL, et al. A New

World Malaria map; plasmodium falciparum endemicity in 2010; malaria journal, 2011,

10: 378 doi:10.1186/1486/1475-2875-10-378.

20. 2012 malaria consortium: Intermittent Preventive Treatment. Available at

http://www.malariaconsortium.org/page.php?id=114 (Accessed on 12/01/13).

21. WHO (2010): Guidelines for the Treatment of Malaria (Report) (2nd Ed.). Available at:

Error! Hyperlink reference not valid.. (Accessed on 12/01/2013).

22. WHO.Haemoglobin concentrations for the diagnosis of anaemia and assessment of

severity. Vitamin and Mineral Nutrition Information System. Geneva, world Health

Organization, 2011(WHO/NMH/NHD/MNM/11.1)

(http://www.who.int/vmnis/indicators/haemoglobin.pdf) accessed 15/8/13.

122

23. Zoakah AI, Envuladu EA, Bello DA, Mafwala SM: prevalence and outcome of malaria

amongst under five children seen at comprehensive Health Centre, Gindiri. Journal of

Medicine in the Tropics 2012, V0l 14, NO 1.

Available at hppt://www.ajol.info/index.php/gjass (Accessed on 12/01/2013).

24. Daboer JC, Chongle MP, Ogbonna C; Malaria parasitaemia and household use of

insecticide treatment bed nets: A Cross-Sectional Survey of under-five in Jos, Nigeria.

Niger Med J [Serialonline] 2010;51:5-9.

Available from hppt://www.nigeriamedj.com/text.asp?2010/51/1/5/70981 (Accessed on

12/01/13).

25. Elden S, Umar A, Ojo A, Ayenigba B. Taking RDTs to the frontline: successes and

challenges in Nigeria. Africa Health, 2013; 35,Number 5:21-24.

26. Poinar G. "Plasmodium dominicana n. sp. (Plasmodiidae: Haemospororida) from

Tertiary Dominican amber". Syst. Parasitol.2005; 61 (1): 47–52. doi:10.1007/s11230-

004-6354-6. PMID 15928991.

27. Joy DA, Feng X, Mu J, Furuya T, Chotivanich K, Krettli AU,et al. "Early origin and

recent expansion of Plasmodium falciparum". Science 2003; 300 (5617): 318–21.

doi:10.1126/science.1081449. PMID 12690197.

28. Hayakawa T, Culleton R, Otani H, Horii T, Tanabe K. "Big bang in the evolution of

extant malaria parasites". Mol Biol Evol .2008;25 (10): 2233–9.

doi:10.1093/molbev/msn171. PMID 18687771.

29. Liu W, Li Y, Learn GH, Rudicell RS, Robertson JD, Keele BF,et al. "Origin of the

human malaria parasite Plasmodium falciparum in gorillas". Nature .2010; 467 (7314):

420–5. doi:10.1038/nature09442. PMC 2997044. PMID 20864995.

30. Canali S. "Researches on thalassemia and malaria in Italy and the origins of the

"Haldane hypothesis"". Med Secoli 2008; 20 (3): 827–46. PMID 19848219.

123

31. Sallares R, Bouwman A, Anderung C. "The Spread of Malaria to Southern Europe in

Antiquity: New Approaches to Old Problems". Med Hist 2004;48 (3): 311–28.

PMC 547919. PMID 16021928.

32. Neghina R, Neghina AM, Marincu I, Iacobiciu I. "Malaria, a Journey in Time: In Search

of the Lost Myths and Forgotten Stories". Am J Med Sci 2010;340 (6): 492–498.

doi:10.1097/MAJ.0b013e3181e7fe6c. PMID 20601857.

33. Cox F. "History of Human Parasitology". Clin Microbiol 2002;Rev 15 (4): 595–612.

doi:10.1128/CMR.15.4.595-612.2002. PMC 126866. PMID 12364371.

34. Lalremruata A, Ball M, Bianucci R, Welte B, Nerlich AG, Kun JF,et al. "Molecular

identification of falciparum malaria and human tuberculosis co-infections in mummies

from the Fayum depression (lower Egypt)". PLoS One 2007;8 (4). PMC 3614933.

e60307.

35. Hempelmann E, Krafts K. "Bad air, amulets and mosquitoes: 2,000 years of changing

perspectives on malaria". Malar J. 2013;12 (1): 213. doi:10.1186/1475-2875-12-232.

PMID 23835014.

36. CDC- Malaria; About malaria: History of malaria. Available at [email protected]

(Accessed on the 11/11/2013)

37. Bill and Melinda Gates Foundation: Malaria strategy overview. Available at

http://www.gatesfoundation.org/what-we-Do/Global-Health/malaria. (Accessed on the

11/11/2013).

38. Mosquito malaria vector; Available at http://www.map.ox.ac.uk/explore/mosquito-

malaria-vectors/ (Accessed on the 11/12/13 ).

39. Malaria Site: Anopheles mosquito; Available at http://www.malariasite.com/index.htm.

(Accessed on the 11/12/13).

124

40. World Health Organization: World malaria report 2012; Available at

http://www.who.int/malaria/publications/worldmalaria_report_2012/wmr2012_no_profi

les.pdf.(Accessed on the 11/12/13).

41. Nadjm B, Behrens RH: Malaria, an update for Physicians; Infectious Disease clinics of

North America.2012; 26(2):243 -59.

42. Oliver C ; Global malaria mortality Between 1980-2010:A Systematic analysis ;

(February 28 ;2012 ).Available at http://journalistsresourse.org/studies/govern malaria

mortality_1980-2010_systemic_analysis/. (Accessed on 11/12/13)

43. Murray CJ, Rosenfeld LC, Lim SS, Andrews KG, Foreman KJ, Haring D, et al. "Global

malaria mortality between 1980 and 2010: A systematic analysis". Lancet 2012; 379

(9814): 413–31.

44. Hartman TK, Rogerson SJ, Fischer PR. "The impact of maternal malaria on newborns".

Annals of Tropical Paediatrics 2010;30 (4): 271–82.

45. Taylor WR, Hanson J, Turner GD, White NJ, Dondorp AM. "Respiratory manifestations

of malaria". Chest 2012;142 (2): 492–505.

46. Kajfasz P. "Malaria prevention". International Maritime Health .2009; 60 (1–2): 67–70.

47. Howitt P, Darzi A, Yang GZ, Ashrafian H, Atun R, Barlow J, et al. "Technologies for

global health". The Lancet 2010;380 (9840): 507–35.

48. Layne SP. "Principles of Infectious Disease Epidemiology" (PDF). EPI 220. UCLA

Department of Epidemiology. Archived from the original on 2006-02-20. Retrieved

2007-06-15.

49. Ngomane L, De Jager C. Changes in malaria morbidity and mortality in Mpumalanga

province, South Africa (2001-2009): a retrospective study. Malaria Journal 2012.11:19.

125

50. Guerra CA, Hay SI, Lucioparedes LS, Gikandi PW, Tatem AJ, Noor AM,et al.

"Assembling a global database of malaria parasite prevalence for the Malaria Atlas

Project". Malaria Journal2007; 6 (6): 17.

51. Hay SI, Okiro EA, Gething PW, Patil AP, Tatem AJ, Guerra CA,et al. "Estimating the

global clinical burden of Plasmodium falciparum malaria in 2007". PLoS Medicine

2010; 7 (6): e1000290. PMC 2885984. PMID 20563310.

52. Gething PW, Patil AP, Smith DL, Guerra CA, Elyazar IR, Johnston GL,et al. "A new

world malaria map: Plasmodium falciparum endemicity in 2010". Malaria Journal

2010;10 (1): 378.

53. Feachem RG, Phillips AA, Hwang J, Cotter C, Wielgosz B, Greenwood BM,et al.

"Shrinking the malaria map: progress and prospects". Lancet 2010; 376 (9752): 1566–

78.

54. Greenwood B, Mutabingwa T. "Malaria in 2002". Nature 2002;415 (6872): 670–2.

55. Jamieson A, Toovey S, Maurel M . Malaria: A Traveller's Guide.2006. Struik. p. 30.

56. Abeku TA. "Response to malaria epidemics in Africa". Emerging Infectious Diseases

2007;14 (5): 681–6.

57. Cui L, Yan G, Sattabongkot J, Cao Y, Chen B, Chen X,et al. "Malaria in the Greater

Mekong Subregion: Heterogeneity and complexity". Acta Tropica 2012;121 (3): 227–

39.

58. Machault V, Vignolles C, Borchi F, Vounatsou P, Pages F, Briolant S,et al. "The use of

remotely sensed environmental data in the study of malaria" (PDF). Geospatial Health

2011;5 (2): 151–68.

59. Illustrated lecture notes on Tropical medicine: Malaria ;Geographical distribution

.Available at

126

http://itg.contente.eu/Generated/pubx/173/malaria/geographical_distribution.htm.(Acces

sed on 12/12/13)

60. Bledsoe GH: Malaria primer for clinicians in the United States; Southern Medical

Journal 2005;98 (12): 1197–204; quiz 1205, 1230.

61. Vaughan AM, Aly AS, Kappe SH : Malaria parasite pre-erythrocytic stage infection:

Gliding and hiding ; Cell Host & Microbe 2008;4 (3): 209–18.

62. White NJ.Determinants of relapse periodicity in Plasmodium vivax malaria; Malaria

Journal 2011;10: 297.

63. Richter J, Franken G, Mehlhorn H, Labisch A, Häussinger D: What is the evidence for

the existence of Plasmodium ovale hypnozoites? ; Parasitology Research 2010;107 (6):

1285–90.

64. Tilley L, Dixon MW, Kirk K: The Plasmodium falciparum-infected red blood cell ;

International Journal of Biochemistry and Cell Biology 2011;43 (6): 839–42.

65. Mens PF, Bojtor EC, Schallig HDFH. "Molecular interactions in the placenta during

malaria infection". European Journal of Obstetrics & Gynecology and Reproductive

Biology 2012;152 (2): 126–32.

66. Rénia L, Wu Howland S, Claser C, Charlotte Gruner A, Suwanarusk R, Hui Teo T, et al

:Cerebral malaria: mysteries at the blood-brain barrier ; Virulence 2012;3 (2): 193–201.

67. Kwiatkowski DP: How malaria has affected the human genome and what human

genetics can teach us about malaria; American Journal of Human Genetics. 2005;77 (2):

171–92.

68. Hedrick PW: Population genetics of malaria resistance in humans; Heredity 2011;107

(4): 283–304.

127

69. Weatherall DJ: Genetic variation and susceptibility to infection: The red cell and

malaria; British Journal of Haematology 2008;141 (3): 276–86.

70. Bhalla A, Suri V, Singh V: Malarial hepatopathy ;Journal of Postgraduate Medicine

2006;52 (4): 315–20.

71. Abba K, Deeks JJ, Olliaro P, Naing CM, Jackson SM, Takwoingi Y, et al: Rapid

diagnostic tests for diagnosing uncomplicated P. falciparum malaria in endemic

countries ; In Abba, Katharine. Cochrane Database of Systematic Reviews 2011;(7):

CD008122.

72. Schlagenhauf-Lawlor P. Travelers' Malaria.2008; PMPH-USA. ISBN 978-1-55009-336-

0. pp. 70–1

73. Cowman AF, Berry D, Baum J . "The cellular and molecular basis for malaria parasite

invasion of the human red blood cell". Journal of Cell Biology 2012;198 (6): 961–71.

74. Arrow KJ, Panosian C, Gelband H, Institute of Medicine (U.S.). Committee on the

Economics of Antimalarial Drugs (2004). Saving Lives, Buying Time: Economics of

Malaria Drugs in an Age of Resistance. National Academies Press. p. 141. ISBN 978-0-

309-09218-0.

75. Owusu-Ofori AK, Parry C, Bates I. "Transfusion-transmitted malaria in countries where

malaria is endemic: A review of the literature from sub-Saharan Africa". Clinical

Infectious Diseases 2010;51 (10): 1192–8.

76. CDC-Malaria: About malaria; Disease.

Available at www.cdc.gov/malaria/about/index.html.( Accessed on 11/11/13)

77. Ferri FF (2009). Protozoal infections". Ferri's Color Atlas and Text of Clinical

Medicine. Elsevier Health Sciences.2009; Chapter 332 p. 1159. 978-1-4160-4919-7.

78. Fairhurst RM, Wellems TE. "Chapter 275. Plasmodium species (malaria)". In Mandell

GL, Bennett JE, Dolin R (eds). Mandell, Douglas, and Bennett's Principles and Practice

128

of Infectious Diseases 2 2010; (7th ed.). Philadelphia, Pennsylvania: Churchill

Livingstone/Elsevier. pp. 3437–3462. ISBN 978-0-443-06839-3.

79. Nadjm B, Behrens RH. "Malaria: An update for physicians". Infectious Disease Clinics

of North America 2012; 26 (2): 243–59.

80. Bartoloni A, Zammarchi L. "Clinical aspects of uncomplicated and severe malaria".

Mediterranean Journal of Hematology and Infectious Diseases 2012; 4 (1): e2012026.

81. Beare NA, Taylor TE, Harding SP, Lewallen S, Molyneux ME. "Malarial retinopathy:

A newly established diagnostic sign in severe malaria". American Journal of Tropical

Medicine and Hygiene 2006;75 (5): 790–7.

82. WHO Criteria for Severe Falciparum Malaria.

Available at http://www.mymedal.org/index.php?n=military.240107. (Accessed on

11/12/13).

83. Bell DR, Jorgensen P, Christophel EM, Palmer KL. Malaria risk: estimation of the

malaria burden. Nature. 2005;437:E3–E4. [PubMed]

84. Reyburn H, Mbakilwa H, Mwangi R, Mwerinde O, Olomi R, Drakeley C,et al. Rapid

diagnostic tests compared with malaria microscopy for guiding outpatient treatment of

febrile illness in Tanzania: randomised trial. BMJ. 2007;334:403.

85. Malaria Facts. CDC website. [Accessed October 10, 2013]. Available at:

http://www.cdc.gov/malaria/facts.htm

86. Curing malaria together. MMV website. [Accessed October 16, 2013]. Available at:

http://www.mmv.org.

87. Looareesuwan S. Malaria. In: Looareesuwan S, Wilairatana P, editors. Clinical Tropical

Medicine. 1st ed. Bangkok, Thailand: Medical Media; 1999. pp. 5–10

129

88. Mwangi TW, Mohammed M, Dayo H, Snow RW, Marsh K. Clinical algorithms for

malaria diagnosis lack utility among people of different age groups. Trop Med Int

Health. 2005;10:530–536.

89. Reyburn H, Mbatia R, Drakeley C, Carneiro I, Mwakasungula E, Mwerinde O,et al.

Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a

prospective study. BMJ. 2004;329:1212.

90. McMorrow ML, Masanja MI, Abdulla SM, Kahigwa E, Kachur SP. Challenges in

routine implementation and quality control of rapid diagnostic tests for malaria-Rufiji

District, Tanzania. Am J Trop Med Hyg. 2008;79:385–390.

91. Perkins BA, Zucker JR, Otieno J, Jafari HS, Paxton L, Redd SC,et al. Evaluation of an

algorithm for integrated management of childhood illness in an area of Kenya with high

malaria transmission. Bull World Health Organ. 1997;75:33–42.

92. Weber MW, Mulholland EK, Jaffar S, Troedsson H, Gove S, Greenwood BM.

Evaluation of an algorithm for the integrated management of childhood illness in an area

with seasonal malaria in the Gambia. Bull World Health Organ. 1997;75:25–32.

93. Tarimo DS, Minjas JN, Bygbjerg IC. Malaria diagnosis and treatment under the strategy

of the integrated management of children illness (IMCI): relevance of laboratory support

from the rapid immunochromatographic tests of ICT malaria P.f/P.v and OptiMAL. Ann

Trop Med Parasitol. 2001;95:437–444.

94. Kyabayinze DJ, Tibenderana JK, Odong GW, Rwakimari JB, Counihan H. Operational

accuracy and comparative persistent antigenicity of HRP2 rapid diagnostic tests for

Plasmodium falciparum malaria in a hyperendemic region of Uganda. Malar J.

2008;7:221.

130

95. Bhandari PL, Raghuveer CV, Rajeev A, Bhandari PD. Comparative study of peripheral

blood smear, quantitative buffy coat and modified centrifuged blood smear in malaria

diagnosis. Indian J Pathol Microbiol. 2008;51:108–112.

96. Ngasala B, Mubi M, Warsame M, Petzold MG, Massele AY, Gustafsson LL, et al.

Impact of training in clinical and microscopy diagnosis of childhood malaria on anti-

malarial drug prescription and health outcome at primary health care level in Tanzania:

a randomized controlled trial. Malaria J. 2008;7:199.

97. Tagbor H, Bruce J, Browne E, Greenwood B, Chandramohan D. Performance of the

OptiMAL dipstick in the diagnosis of malaria infection in pregnancy. Ther Clin Risk

Manag. 2008;4:631–636.

98. Zerpa N, Pabón R, Wide A, Gavidia M, Medina M, Cáceres JL, et al.Evaluation of the

OptiMAL test for diagnosis of malaria in Venezuela. Invest Clin. 2008;49:93–101.

99. Ratsimbasoa A, Fanazava L, Radrianjafy R, Ramilijaona J, Rafanomezantsoa H,

Ménard D. Evaluation of two new immunochromatographic assays for diagnosis of

malaria. Am J Trop Med Hyg. 2008;79:670–672.

100. Endeshaw T, Gebre T, Ngondi J, Graves PM, Shargie EB, Ejigsemahu Y,et al.

Evaluation of light microscopy and rapid diagnostic test for the detection of malaria

under operational field conditions: a household survey in Ethiopia. Malar J.

2008;7:118.\

101. Lee SW, Jeon K, Jeon BR, Park I. Rapid diagnosis of vivax malaria by the SD Bioline

Malaria Antigen test when thrombocytopenia is present. J Clin Microbiol.

2008;46:939–942.

102. Harvey SA, Jennings L, Chinyama M, Masaninga F, Mulholland K, Bell DR.

Improving community health worker use of malaria rapid diagnostic tests in Zambia:

package instructions, job aid and job aid-plus-training. Malar J. 2008;7:160.

131

103. Holland CA, Kiechle FL. Point-of-care molecular diagnostic systems-past, present and

future. Curr Opin Microbiol. 2005;8:504–509.

104. Vo TK, Bigot P, Gazin P, Sinou V, De Pina JJ, Huynh DC,et al. Evaluation of a real-

time PCR assay for malaria diagnosis in patients from Vietnam and in returned

travelers. Trans R Soc Trop Med. 2007;101:422–428.

105. Warhurst DC, Williams JE. Laboratory diagnosis of malaria. J Clin Pathol.

1996;49:533–538.

106. Bharti AR, Patra KP, Chuquiyauri R, Kosek M, Gilman RH, Llanos-Cuentas A, et

al.Polymerase chain reaction detection of Plasmodium vivax and Plasmodium

falciparum DNA from stored serum samples: implications for retrospective diagnosis

of malaria. Am J Trop Med Hyg. 2007;77:444–446.

107. Chotivanich K, Silamut K, Day NPJ. Laboratory diagnosis of malaria infection-a short

review of methods. Aust J Med Sci. 2006;27:11–15.

108. Payne D. Use and limitations of light microscopy for diagnosing malaria at the primary

health care level. Bull World Health Organ. 1988;66:621–628.

109. Ohrt C, Purnomo, Sutamihardia MA, Tang D, Kain KC. Impact of microscopy error on

estimates of protective efficacy in malaria prevention trials. J Infect Dis.

2002;186:540–546.

110. Erdman LK, Kain KC. Molecular diagnostic and surveillance tools for global malaria

control. Travel Med Infect Dis. 2008;6:82–99.

111. World Health Organization. WHO information consultation on recent advances in

diagnostic techniques and vaccines for malaria: a rapid dipstick antigen capture assay

for the diagnosis of falciparum malaria. Bull World Health Organ. 1996;74:47–54.

112. Bell D, Wongsrichanalai C, Barnwell JW. Ensuring quality and access for malaria

diagnosis: how can it be achieved? Nat Rev Microbiol. 2006;4:S7–S20.

132

113. List of known commercially available antigen-detecting malaria RDTs. World Health

Organization.

[Accessed November 12, 2013]. Available at: http://www.wpro.who.int/sites/rdt.

114. Park TS, Kim JH, Kang CI, Lee BH, Jeon BR, Lee SM, et al.Diagnostic usefulness of

SD malaria antigen and antibody kits for differential diagnosis of vivax Malaria in

patients with fever of unknown origin. Korean J Lab Med. 2006;26:241–245.

115. Kim SH, Nam MH, Roh KH, Park HC, Nam DH, Park GH,et al.Evaluation of a rapid

diagnostic test specific for Plasmodium vivax. Trop Med Int Health. 2008;13:1495–

1500.

116. McCutchan TF, Piper RC, Makler MT. Use of malaria rapid diagnostic test to identify

Plasmodium knowlesi infection. Emerg Infect Dis. 2008;14:1750–1752.

117. Chilton D, Malik AN, Armstrong M, Kettelhut M, Parker-Williams J, Chiodini PL.

Use of rapid diagnostic tests for diagnosis of malaria in the UK. J Clin Pathol.

2006;59:862–866.

118. Noedl H, Yingyuen K, Laoboonchai A, Fukuda M, Sirichaisinthop J, Miller RS.

Sensitivity and specificity of an antigen detection ELISA for malaria diagnosis. Am J

Trop Med Hyg. 2006;75:1205–1208.

119. Doderer C, Heschung A, Guntz P, Cazenave JP, Hansmann Y, Senegas A, et al. A new

ELISA kit which uses a combination of Plasmodium falciparum extract and

recombinant Plasmodium vivax antigens as an alternative to IFAT for detection of

malaria antibodies. Malar J. 2007;6:19.

120. Murray CK, Bell D, Gasser RA, Wongsrichanalai C. Rapid diagnostic testing for

malaria. Trop Med Int Health. 2003;8:876–883.

121. Murray CK, Gasser RA, Jr, Magill AJ, Miller RS. Update on rapid diagnostic testing

for malaria. Clin Microbiol Rev. 2008;21:97–110.

133

122. Raghavendra K, Barik TK, Reddy BP, Sharma P, Dash AP (2011). "Malaria vector

control: From past to future". Parasitology Research 108 (4): 757–79..

123. Howitt P, Darzi A, Yang GZ, Ashrafian H, Atun R, Barlow J,et al. "Technologies for

global health". The Lancet 2012; 380 (9840): 507–35.

124. Miller JM, Korenromp EL, Nahlen BL, W Steketee R . "Estimating the number of

insecticide-treated nets required by African households to reach continent-wide

malaria coverage targets". Journal of the American Medical Association 2007; 297

(20): 2241–50.

125. Schlagenhauf-lawler P .Traveller’s Malaria ;Illustrated: PHPH – USA,2008, PP.215.

126. CDC. Malaria /malaria worldwide/How to reduce malaria’s impact. Available at

http://www.cdc.gov/malaria_worldwide/impact.html. Accessed on 11/12/13.

127. Indoor Residual Spraying: Use of Indoor Residual Spraying for Scaling Up Global

Malaria Control and Elimination. WHO Position Statement (Report). World Health

Organization. 2006.

128. Van den Berg H. "Global status of DDT and its alternatives for use in vector control to

prevent disease". Environmental Health Perspectives 2009; 117 (11): 1656–63.

129. Pates H, Curtis C. "Mosquito behaviour and vector control". Annual Review of

Entomology 2005; 50: 53–70.

130. WHO (2011).Global Malaria Programme: The use of DDT in malaria vector control.

WHO Position Statement.

131. East African Community Health: Malaria Prevention and control. Available at

http://www.eac.int/health/index.php?option=com_docman&Itemid=155.

(Accessed on 12/12/13)

134

132. WHO/GMP Technical Expert Group on Preventive chemotherapy, Geneva 4-6 May

2011: Report of the Technical Consultation on seasonal malaria chemoprevention (

SMC )

133. Kwelu M, Liu D, Adjuik M, Binka F, Seidi M, Greenwood B, et al. Seasonal

intermittent preventive treatment for the prevention of anaemia and malaria in

Ghanaian children. A randomized, placebo controlled rail. PIOS ONE 2008. 3(12)

e4000.

134. Dicko A, Diallo Al, Tembine I, Dicko Y, Dara N, Sidibe Y et al. Intermittent

preventive treatment of malaria provides substantial protection against malaria in

children already protected by an insecticide treated bed net in Mali: A randomized,

double-blind, placebo controlled trial. PLOS Med 2011. 8(2): e1000407.

doi:10.1371/journal.pmed.1000407.

135. Ahorlu CK, Koram AK, Seakey AK, Weiss MG. Effectiveness of combined IPT for

children and timely home treatment for malaria control. Malaria Journal 2009, 8:292.

136. Ahorlu CK and Koram KA. Intermittent Preventive treatment for children (IPTC)

combined with timely home treatment for malaria control. Malaria Journal 2012, 11

(suppl 1): P108.

137. Richards PW. Sulphonamide and sulphones. Antimalaria Drugs. Jansen Malaria

Journal 2011,10:70.Available at http://www.malariajournal.com/content/10/1/70

(Accessed 12/01/13).

138. Pitmang SL, Thatcher TD, Madaki JKA, Comparism of S-P with and without

chloroquine for uncomplicated malaria in Nigeria. Am J Trop Med Hyg, 72 (3), 2005,

pp 263-266.

139. Dicko A, Sagara I, Sissoko M, Guindo O, Diallo A, Kone, M. et al. Impact of

Intermittent Preventive Treatment with sulphadoxine-pyrimethamine targeting the

135

malaria transmission season on the incidence of clinical malaria in children of 6

months to 10 years in Kambila, Mali, Am J trop Med Hyg 2004: 71(suppl): 6 Abstract

140. Cisse B, Sokhna C, Boulanger D,Millet J,Ba EH, Richardson K, et al.Seasonal

intermittent Preventive treatment with Artesunate and sulfadoxine-pyrimethamine for

prevention of malaria in Senegalese children: A Randomised placebo-controlled

double-blind trial. Lancet 2006;367:659-67.

141. Bojang K, Akor F, Bittaye O, Conway D, Bottomley C, et al. A randomised trial to

compare the safety, tolerability and efficacy of three drug combinations for

intermittent preventive treatment in children. PLoS One. 2010;5: e11225.

142. Wilson AL. A Systematic review and Meta-Analysis of the efficacy and safety of

intermittent preventive treatment of malaria in children (IPTc).PLoS One.2011;6(2):e

16976.

143. Pitt C, Diawara H, Ouedraogo DJ,Diarra S, Kabore H, Kouela K.Intermittent

Preventive Treatment of Malaria in Children:A Qualitative Study of Community

Perceptions and Recommendations in Burkina Faso and Mali. PLoS ONE (2012)

7(3):e32900.

144. Chandramohan D, Owusu-Agyei S, Carneiro I, Awine T, Amponsa-Achiano K.Cluster

randomised trial of intermittent preventive treatment for malaria in areas of high

seasonal transmission in Ghana. British Medical Journal (2005) 331:727-733.

145. Dicko A, Barry A, Dicko M, Diallo AI, Tembine I, Dicko Y, et al. Malaria morbidity

in children in the year after they had received intermittent preventive treatment for

malaria in Mali: A Randomised control trial. PLos ONE (2011) 6(8):e23390.

136

APPENDIX B

CONSENT FORM

Dear Sir/Madam,

I am Dr. Everest Kemas, a resident with Family Medicine Department of the Jos University

Teaching Hospital, Jos.

I am carrying out a study to demonstrate the benefits of using antimalarial given during the season of high malaria transmission in children. This has been demonstrated to be efficacious in preventing malaria in several countries and I want to determine its efficacy in our own setting in the short term.

This is to request your permission to participate in the study.

You will answer the following questions below and be examined to determine if your child is eligible to join the study. When you are deemed eligible, you will be divided into 2 (two) groups. One group will receive an anti-malarial treatment using sulphadoxine-pyrithamine and the other will not. Drugs for proven cases of malaria while you are being followed up will be given free of charge.

You will also be required to allow your child to go for sample collection which will be done by collecting a few drops of blood from the heel of the foot of the child. This is safe and will only cause a temporary pain and mild discomfort. These will be studied for blood levels

(packed cell volume) and presence of malaria parasite.

You will also be required to come for drug administration with S-P for the next two consecutive months during your normal follow-up monthly visit. The child might experience mild side-effect like Nausea vomiting and abdominal discomfort. However, on the 4th month

137 of the study i.e. a month after last S-P dose, you will come for the final sample collection which will be taken at the end of the study, meaning you will be seen 4 times.

You are however free to pull out of the study at anytime and you are not under any obligation to complete the study.

If the above is acceptable to you, please sign below.

Parent/Guardian Dr. Everest Kemas __

Signature of Witness Investigator’s Phone No _____

138

APPENDIX C

QUESTIONNAIRE 1ST VISIT

Effect of Intermittent Preventive Treatment on Prevalence of Malaria Parasitaemia in

Children Attending the Under Five Clinic in SDA

My name is Dr. Everest Kemas and I will be carrying out the study. Please answer the following question as correctly as you can. Thank you for agreeing to be part of this study.

My phone numbers are 08034841007 and 08085840334.

Identification Number

Hospital Number Date

(A) DEMOGRAPHIC

1. Name (initials):

2. Age in months:

3. Sex: M ( ) F ( )

4. Tribe

5. Address

6. Phone Number

7. Religion of Guardian/Parent: Christian ( ), Muslim ( ), Traditional ( )

Others (specify)

8. Mother’s/Guardian Educational level ______

139

9. Father’s Educational level ______

(B) HISTORY

1. Does the child have fever now? Yes ( ) No ( )

2. Is the child currently ill? Yes ( ) No ( )

3. Does the child sleep under a mosquito net?

Yes ( ) No ( ) don’t know ( )

4. Has the child been treated for malaria within the last month?

Yes ( ) No ( ) don’t know ( )

5. How long ago?

1week ( ) 2weeks ( ) 3weeks ( ) 4weeks ( ) don’t know ( )

6. Has the child ever reacted to fansidar or septrin?

Yes ( ) No ( ) don’t know ( )

7. Is the child known with any ailment that may affect his participation in the study? Yes

( ) No ( )

If yes, please specify

 General Examination

Palor ( ) Jaundice ( ) Dehydration ( ) Cyanosis ( )

Pedal oedema ( ) Axiliary temperature ( )

140

 Anthropometrics

 Length

Weight

Weight for height ______

(D) LABORATORY INVESTIGATIONS

PCV

Malaria Parasite Density

+ ( ), ++ ( ), +++ ( ), ++++ ( )

Eligibility: Yes ( ) No ( )

Sulphadoxine-Pyremethamine taken: Yes ( ) No ( )

141

APPENDIX C

QUESTIONNAIRE (FOLLOW UP VISIT)

Effect of Intermittent Preventive Treatment on Prevalence of Malaria Parasitaemia in

Children Attending the Under Five Clinic in SDA

My name is Dr. Everest Kemas and will be carrying out the study. Please answer the following question as correctly as you can. Thank you for agreeing to be part of this study.

My phone numbers are 08034841007 and 08085840334.

Identification Number

Hospital Number Date (2nd visit) (3rd visit)____

(A) HISTORY

Second Visit Third Visit

Has the child had fever Yes No Yes No since the last visit?

How long ago was it? 1 wk 2 wks 3 wks 4 wks 1 wk 2wks 3 wks 4 wks

Was it confirmed for Yes No Yes No malaria?

What was he/she treated ACT[Coartem] ACT[Coartem] with? Quinine Quinine

Chloroquine Chloroquine

Fansidar Fansidar

Other (specify) Other (specify)

Does he/she have fever Yes No Yes No now?

142

Does the child have any of Jaundice Jaundice the symptoms listed? Skin rash Skin rash

Skin Skin discolouration Discolouration

Does the child have any Yes No Yes No other symptom?

If yes, specify

(B) EXAMINATION

2nd VISIT 3rd VISIT  General Examination

Fever (axillary temperature) Jaundice Dehydration Pedal oedema  Anthropometrics

Length Weight Weight for height (C) LABORATORY RESULTS

2nd VISIT 3rd VISIT PCV Malaria Parasite Density + ( ), ++ ( ), +++ ( ), ++++ ( ) + ( ), ++ ( ), +++ ( ), ++++ ( )

143

(D) DRUG (INTERVENTION)

2nd VISIT 3rd VISIT SP taken Yes No Yes No

144

145