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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) BY DR. EVEREST KEMAS (MBBS, UNIVERSITY OF JOS, 2006) DEPARTMENT OF FAMILY MEDICINE, JOS UNIVERSITY TEACHING HOSPITAL, JOS, NIGERIA. MAY 2016. 1 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: ___________________________________ 2 DEDICATION This work is dedicated to GOD Almighty and to all under five children affected by malaria in Nigeria and in Africa. 3 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. 4 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. 5 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 6 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 7 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 8 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 9 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 10 References - - - - - - - - - - 98 JUTH Ethical Clearance - - - - - - - Appendix A Consent Form - - - - - - - - - Appendix B Questionnaire - - - - - - - - - Appendix C 11 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 12 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 13 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 14 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
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