project report on maleria

INTRODUCTION

Malaria is a tropical disease passed on to humans by mosquitoes, and is

present in over 100 countries. Malaria is spread by the female of the Anopheles

species of mosquito. When one of these mosquitoes bites you, it feeds on your

blood and injects malaria parasites into your body. It only takes one bite to infect

you. In some forms of malaria, parasites can stay dormant in your body for years,

occasionally "waking up" and causing you to have more attacks of malaria.

However, you can’t catch malaria from another person, just from a mosquito.

There are four types of malaria:

1. Plasmodium falciparum

2. Plasmodium vivax

3. Plasmodium ovale

4. Plasmodium malariae

The four types of plasmodium parasite include:

Plasmodium falciparum - this is the only malignant form of malaria, and is

predominantly found in Africa. This parasite causes the most severe

symptoms and results in the most fatalities.

Plasmodium vivax - a benign type of parasite found mainly in Asia. It

produces less severe symptoms than plasmodium falciparum, but can stay in

the liver for up to three years, which can result in relapses of the condition.

Plasmodium ovale - a benign parasite that is usually found in Africa. This

type of parasite can stay in your blood for several years without producing

any symptoms.

Plasmodium malarie - this benign parasite is relatively rare and is usually

only found in West Africa.

They’re all dangerous, but Plasmodium falciparum is considered to be the most

serious. It’s responsible for most malaria fatalities. It can sometimes take a year or

more for symptoms of Plasmodium vivax and ovale to appear, while Plasmodium

falciparum usually starts within three months of being bitten.

Occasional isolated outbreaks have been reported in England, particularly by

airport workers, and those who have contact with items imported from other

countries. Altogether, around 2,000 cases of malaria are brought into the UK each

year.

Malaria predominantly affects countries in Africa, South and Central America,

Asia and the Middle East. The disease is particularly widespread in sub-Saharan

Africa, where over 90% of malaria-related deaths occur.

Almost two thirds of all malaria-related deaths occur among the poorest 20% of the

world's population.

In 1998 the World Health Organisation (WHO), UNICEF, World Bank and the

United Nations Development Programme (UNDP) joined forces to fund the Roll

Back Malaria programme. Roll Back Malaria aims to halve malaria-related deaths

by 20101.

Symptoms of malaria tend to appear between 10 days to 4 weeks after the initial

bite. However, in some cases, depending on the type of parasite you are infected

with, it can take a year before your symptoms start to show.

Preventing mosquito bites

Below are a number of measure that you can take to help prevent being bitten by

mosquitoes while travelling in countries where there is a risk of malaria.

Use insect repellent on your skin and in sleeping environments. The most

effective repellents contain diethyltoluamide (DEET). Insect repellents are

available in a variety of forms including, sprays, roll-ons, sticks, plug-in

devices and creams.

Wear trousers, rather than shorts, and shirts that have long sleeves. This is

particularly important during early evening and night time, as this is the

mosquitoes preferred feeding time.

Stay in accommodation that has screen doors, and close windows. In

addition to this (or if this is not possible), sleeping under a mosquito net that

has been treated with insecticide will help you to prevent being bitten.

It is very important that you are aware that any flu-like illness, or anaemia, that

occurs within three months of returning from travelling in places where malaria is

present, may be malaria, even if you took your medicine. If you become ill when

you get back, you should see your GP and mention where you have been on

holiday, and that you may have been exposed to malaria1

“Prevention is better than cure”

Health is the condition of being sound in body, mind or spirit, especially

freedom from physical disease or pain. It is greatly affected by the surrounding

environment, the impact of environment on health has been realized since this

times immemorial. People have been taking various steps to modify their

environment to promote healthy living but certain health problems are still

dominant and constitute major public health problems especially communicable

disease.

Among the many health problems in India, communicable diseases are the

major health problem which are transmitted to man by direct and indirect contact

with the causative agent . the diseases which are indirectly transmitted by

mosquito are dengue, malaria, filaria and Chikungunya among these disease

Malaria is one of the common disease in the community.

Malaria has been a major public health problem, was recognized by Roman

and Greeks who associated it with swampy areas, They postulated that

intermittent fever were due to the “bad odour “ coming from the marshy areas and

thus gave the name malaria (mal=bad+air) to intermittent fever . Inspire of the

fact that today the causative organism is known the name has struck to this

disease.

Malaria is a life threating disease caused by parasite of plasmodium namely

plasmodium falciperum, plasmodium vivax , plasmodium malaria, plasmodium

ovale, which are transmitted exclusively through the bit of infected Anopheles

mosquitoes. the intensity of transmission dependence on factors related to the

parasite , the vector, the human host , the environment, and the climatic conditions

that may affect the abundance and survival of mosquito’s such as rainfall

patterns ,temperature and humidity with the peak during and just after the rainy

session. The disease is characterized by fever with chills or rigor, headache,

vomiting fatigue and other flu like symptoms , these symptoms will appears seven

days or more after the infective mosquito bite, it is diagnosed by blood test and

can be treated with anti malarial drugs.

Malaria can be prevent by combination of following measures ,

The source reduction method includes filling of breeding places, proper covering

of the stored water & insecticidal spraying.

The mosquito avoiding measure are like use of mosquito repellent liquids, coils ,

mats, screening of the houses with insecticide, and wearing cloths that cover the

maximum surface area of the body .

Early detection of the cases and treating with chemoprophylaxis.5

Health education at primary level of prevention aim to prevent the

malaria .it helps in reducing the morbidity and ,mortality of malaria. It also helps

in improving the knowledge of the community people related to

malaria .community health nurse play a major role in preventing the various

disease in the community by delivering health education.

Malaria is one of the major public health problems of the country.

Tumkur is one of the malarious districts of Karnataka. The bulk of malaria

cases are generated in an area where boundaries of four districts meet. These

districts, with high risk Primary Health Centres(PHC) are Chikmangalur (PHC

Kadur), Chitradurga (PHC Hosdurga), Hassan (PHC Arsikere) and Tumkur (PHC

Chikanayakanhalli).

In Tumkur district, 4 Talukas constitute high risk and problem areas. These are

(a) Sira, Chikkanayaakanalli, (b) part of Tiptur, (c) Kyathsandra of Tumkur, and

(d) part of Gubbi. Anaphelus culicifacies (species A) and Anaphelus fluviatilis

(species S) are the two malaria vectors of malaria. The major vector breeding sites

are: 4 dams, 26 712 tanks, 16 943 wells, 55 852 bore wells and rain water

collection sites.

In Tumkur, about 3 000 malaria cases are reported annually; of which 15-

20% constitute Plasmodium falciparum. Malaria API in the district ranged between

2.2 to 5.4 in the last five years. There are two general hospitals (500 beds each), 7

Taluk hospitals (50 beds each) and 28 Ayurvedic hospitals.(4)

In manifestation of severe Plasmodium Falciparum Malaria the signs may

include severe normocytic, normochromic anemia, renal failure, cerebral malaria,

acidosis, acute respiratory distress syndrome, hypoglycaemia, jaundice,

hyperparasitemia, disseminated intravascular coagulation(DIC), haemoglobinuria

convulsions and shock.(1)

The hepatorenal parameters indicating poor prognosis in severe malaria are

elevated serum creatinine >3 mg/dl, total bilirubin > 3mg/dl, elevated liver

enzymes (aspartate transaminase/ alanine transaminase >3 times upper limit of

normal). Malaria affects kidneys leading to both tubulointerstitial damage as well

as glomerulonephritis. Acute renal failure due to acute tubular necrosis occurs in

falciparum malaria. Glomerulonephritis in malaria is due to plasmodium malariae .

Though nephrotic syndrome is commonly associated with Plasmodium malaria it

can also be seen with other malarial species. Renal impairment is common with

adults with severe Plasmodium falciparum malaria, most commonly presents as

acute renal failure. Hepatic involvement commonly presents as jaundice which can

be due to intravascular haemolysis of the red blood cells(RBC), DIC,

microangiopathic haemolysis and malarial hepatitis.

The haematogical parameters indicating poor prognosis are leucocyte count

> 12,000/microl, severe anemia (Haemoglobin < 5gm/dl) and coagulopathy

(1).Common hematological abnormalities seen are anemia, thrombocytopenia with

coagulopathy. Pancytopenia reflects hypersplenic state in malaria due to increased

peripheral destruction of all cell lineages.

Since Tumkur is an endemic area and due to continually escalating malaria

cases in our locality, it is ideal for a study to be conducted here, to know the

hepatorenal and hematological profile, and hence the degree of complication that

can arise from these deranged parameters .No study has been undertaken in this

area involving all the three parameters. Hence this study is being undertaken.

NEED OF THE STUDY

Much of the ill health in India is due to poor environmental health in term

of unprotected water, air pollution ,soil pollution ,poor housing, vectors around us,

high death and morbidity rate are due to poor environmental sanitation, which

needs improvement in the battle of prevention of diseases and promotion of

community health.

Housing condition represents a major part of the environment, where the

people live. According to family survey (2001) carried out by Indian Government,

found that only 19% of rural population live in Pucca house, while remaining are

living in semi-pucca, kacha house with mud walls and thatched roofs, un hygienic

conditions of housing and Rugs in open space of houses act as reservoir of

collection of water which can cause breeding mosquitoes causing life threatening

diseases such as chickungunya ,dengue, filaria and Malaria.

Disease produced by arthropods constitute major health problem in rural

and urban. Arthropods comprise varied living thing in the surrounding man. It is

estimated that about 300-500 million cases of malaria occur each year world wide,

the problem of malaria can be divided into rural, urban and tribal malaria, Rural

malaria contribute to 47.4% , tribal belt to 42% and urban malaria to 10.6%.

All the countries of the region except Maldives have indigenous malaria

transmission . An estimated 1.3 billion people or 85% of the total population are

at risk of malaria . 30% of this population live in areas with moderate to high risk

of malaria mainly in India.

The burden of communicable dieses is no less in our country;

communicable diseases constitute 30% of deaths in the country more than 1.5

million people suffer from malaria. In an analysis of emerging infectious disease

between 1904 to 2004 it has been observed that the majority of 80% ,are caused

by vector born dieses are responsible for 23% of them .

It is observed that malaria is a major disease reported by house holds the

incidents of Malaria is more in rural, about 7% of the household also reported

Malaria, which is very common dieses in rural areas due to lack of drainage

facilities

It has been reported in 2001 Karnataka population census , Gulbarga

District is primarily a rural district 72% of total population lives in rural areas and

literacy level among these people is 42.28%.

In the year 2002, oxford university team at the welcome trust research

laboratory in Kenya created an extraordinary world map of malaria suffers. It is

said that there were 300-600 million clinical cases of malaria identified in world

and 1.84 million cases from India, and 132609 were reported from Karnataka.

In the year 2003, WHO burden report in India said it has 1.87 million cases

of malaria among these 0.86 million (45.85 %) are P,falciparum and the API rate

was 1.82 and there was 1006 death also reported .

In the year 2006, a total of 1.79 million cases of malaria form India and

62864 cases of malaria were reported from Karnataka state, among these 16446

cases of P. falciparum , and 29 deaths were reported from the Karnataka.

In the year 2010, a total of 92, 81,666 Blood slide are examined, and 44,319

cases of malaria were reported from Karnataka, of the 7936 cases were

P.falciparum and 11 deaths was reported.

During the community posting in village researcher found that the residents

of their study area are generally ignorant about the prevention of malaria, there

were no houses found to be having mosquito mesh on their doors & window,

many are storing water in open container and water tanks are also left opened. It is

found that environmental condition in nandoor village is poor and people living in

the area are more prone to get infections not only malaria but from other vector

born diseases, so researcher felt the need to conduct a study on malaria among

adults which help them to gain more knowledge about the disease condition and

its prevention.

REVIEW OF LITERATURE

Review of literature is a broad, comprehensive, in depth, systematic and

critical review of scholarly publication, unpublished scholarly print material,

audiovisual materials and personal communications.

Review of literature is the systematic and critical review of the important

published scholarly literature on a particular topic . this helps in investigator to

find out what is already known and what problem remain to be solved , since

effective research is based on past knowledge , this exercise provides useful

hypothesis and helpful suggestions for significant investigations.

A prospective study was conducted by Fernando D, De silva D , et al

(1999) in a malaria-endemic area of srilanka to determine the short – term impact

of an acute attack of malaria on the cognitive performance of 648 school children

divided into three group in such as , children with malaria , children with non-

malarial fever and healthy control . cognitive performance in language and

mathematic at the time of presentation and two week later were assessed . at the

time of presentation , children with malaria scored significantly less in both

mathematics and languages than children with non-malarial fever and controls .

two week later , the mathematics and language scores of children with malaria

improved . but the scores were significantly lower than the scores of children with

non-malarial fever (p<0.001) and control s (p0.001). these finding suggest that an

acute attack of uncomplicated malaria causes significant short term impairment of

cognitive performance. The impairment persists for more than two week and

appears to be cumulative with repeated attacks of malaria.

A study were carried out in 2009 and 2010 by Rehman AM, et al’ in Bioko

Island, Mainland quaterial Guinea and Malavia to monitor infection with

plasmodium falciparum in children mosquito net use. Net condition and spray

status of houses nets were classified by their condition. The association between

infection and coverage of interventions was investigated. The result suggest that

there was reduced odds of infection with plasmodium falciparum in children

sleeping under ITNs (insecticide treated nets), that were intact (odds ; ratio(or);

0.65 that is 95% . CI : 0.55-0.77 and “OR ;0.81,95% CI :0.56-1.18 in Equatorial

Guinea and in Malawi respectively ) but the protective effect become less with

increasingly worse condition of the net. There was evidence for a linear trend in

infection per category increase in deterioration of net .

WHO in 2009repoted that prevention of malaria focus on reducing the

transmission disease by controlling the malaria bearing mosquitoes. The two main

interventions for malaria control are:

Use of mosquito nets treated with long lasting insecticides, a long lasting effective

method

Indoor residual spraying of insecticides.16

A study was conducted in 2001 at Allahabad (UP) to evaluate the impact of

delta-methrin impregnated mosquito nets on malaria incidence, mosquito density

any adverse effect along user and collateral effects on bed bugs and house flies. A

field trial was carried out over a period of 3 years in 2 adjacent military stations,

keeping one as atrial and other as a control station . During 1st year baseline data

were collected, and during next two year residual spray was replaced with use of

deltamethrin impregnated mosquito nets in trial station. The use of deltametrin

treated bed nets resulted in a significant decline in malaria incidence and annual

parasite index (API).

In 2001 a study was conducted on a community based health education

programme for bio environmental control of malaria through folk theater

(kalajatha) in rural India , this study was carried out under the primary health care

system involving the local community and various potential partners. Impact of

this program was assessed after two months on exposed Vs non-exposed

respondents. The result suggest that the exposed had significant in knowledge and

change in attitude about malaria and its control strategies, especially on bio

environmental measures (p<0.001).they could easily associate clear water with

anopheline breeding and role of larvivorous fish in malaria control which

subsequently resulted in reduction of malaria cases.

An assessment was done by alilio MS et al (2004) in Tanzania to determine

the extent to which the primary health care services have contributed to reducing

the burden of malaria since the system was initiated in the 1980s. it covered house

hold interviews with a stratified sample of 1250 respondent, and in death

interviews with all 175 health care providers in the 35 health facilities with in the

district, The average number of clinical ,malaria episodes per child below 5 years

of age remained between 3 and 3.5 episodes per year in the district since the 1960s

.the comparison of cases expected in the population less than 5 years old with

those seen the district heath facilities shows a coverage rate of 33% . Furthermore,

between 1990 -2003, a little training on malaria was provided to health staff. The

findings imply a limited effectiveness of district health services on malaria

control.

In year 2004 Yenug S. Pongtavornpinyo W. investigated in Washington

that is anti-malarial drug resistance enhances towards increasing mortality, and

economic and social cost. He found that combination therapy is better than mono

therapies in controlling malaria.

It was reported that malaria can be prevented by mosquito screening,

protective clothing ,insect repellants, by health education, case

finding ,chemoprophylaxis by chloroquine , myloquine , proguanil , doxycycline ,

chloroquine co administered with proguanil.

A pilot study was undertaken by Seleena P et al (2004) in malasia , to

determine the effectiveness of space of insecticides for the control of malaria in

Ranau , a distric in sabah. This study does indicate that space application of

larvicides adulticides or a mixture of both is able to reduce the malaria vector

population and the malaria transmission. A larger scale study needs to be

undertaken in a malaria-affected villages / province to determine whether space

application of insecticides together with other malaria control measures will be

able to eradicate malaria.

A cross sectional study was conducted to determine the availability and

utilization of malaria prevention strategies in pregnancy among 260 antenatal

mothers in Jharkhand and Chhattisgarh, India. The result reveals that in Jharkhand

90 %pregnant women used bed nets in the house and in Chhattisgarh the rate was

40 % where Asante malaria chemo-prophylaxis was less than 1 % hence the

researcher concluded that a target increase of educational effort should be made

among antenatal mother for the prevention of malaria.

A study was conducted by A.P Velip, et al’ in December 2004 on

determinations of hospital stay among malaria patients at a tertiary care hospital

Goa. Out of 748 patients admitted with malaria in the hospital, 77.4% (579 /748)

were male and 22.6% (169/748)females. among all patients 14.2% (106-748)had

Vivax , 63.4% (474/748) falciparum and 22.4% ( 168/748)had mixed malaria

infection .in this study 78.3% (586/748)patients improved ,2.5% (19/748)died and

19.1% (143/748)were discharged against medical advice although needed longer

stay.

In 2005 operational efficiency of the national Anti-malaria program in

“high risk” rural areas of vadodra district was evaluated,from 269 high risk

villages . 20 villages were selected randomly from 10 taluks, the monthly blood

examination rate ( MBER)targets could not be achived in 8 out PHC’s the

performance of 50% of malaria clinics and 94% of the village was poor to average

, the study has found that there were lapses in the operation of the NAMP.

Malaria is the most important protozoal parasitic disease of humans

affecting more than 1 billion people world wide and causing 1-3 million death each

year. (1)The word malaria derives its origin from the Italian “mal-aria” meaning

bad air.

Charles Louis Alphonse Laveran, a French army surgeon stationed in

Constantine, Algeria, was the first to notice parasites in the blood of a patient

suffering from malaria on the 6th of November 1880. For his discovery, Laveran

was awarded the Nobel Prize in 1907.On August 20th, 1897, Ronald Ross as the

first to demonstrate that malaria parasites could be transmitted from infected

patients to mosquitoes.

In India, formal malaria control programmes were started under British

colonial rule and continued after Indian Independence in 1948. Early malaria

control efforts involved removal of breeding sites and later used chemicals such as

the larvicides Paris green and kerosene. In 1946, pilot schemes using DDT were set

up in several areas, including Karnataka. Usefulness of DDT prompted the launch

of the National Malaria Control Programme (NMCP) in 1953. The programme saw

tremendous impact and the annual number of cases came down to 49151 by 1961,

with a belief that malaria could be eradicated in seven to nine years. On the

contrary, malaria began to re-emerge in 1965. With increase in malaria cases in

urban areas, The Urban Malaria Scheme (UMS) was launched in 1971. In 1977 the

Modified Plan of Operation (MPO) was launched. The National Anti Malaria

Programme (NAMP) was launched in 1995. In 2004, the integrated National

Vector Borne Disease Control Programme (NVBDCP) for the prevention and

control of vector borne diseases was launched. Despite all these measures malaria

still prevails causing significant morbidity and mortality.

Causes of anemia in malaria are- hemolysis of infected RBC’s, hemolysis of

non infected RBC’s [black water fever],dyserthryopoesis, splenomegaly and folate

depletion.

Renal dysfunction can also arise due to hemoglobinuria [black water fever] ,

oliguria and anuria due to acute tubular necrosis.(7)Nephrotic syndrome is seen in

plasmodium malariae infection.(7) Plasmodium malariae infection is prevalent in

tumkur.(3) Renal dysfunction usually resolves , urine flow resumes in a median of

4 days and serum urea creatinine returns to normal in a mean of 17 days.

Hepatic involvement manifests commonly as mild hemolytic jaundice.

Severe jaundice can be seen due to hemolysis, hepatocyte injury and

cholestasis .When compared to other vital organ dysfunction, liver dysfunction

carries a poor prognosis.Another study has also shown that liver involvement has

poor outcome.

Hence this study is conducted to study the derangement in biochemical

parameters and its correlation with outcome of disease.

A study conducted by Lon et al between January 2006 and June 2009, a

total of 537 records from suspected severe malaria cases were reviewed from

patients admitted or discharged from BRH (Battambang Referral Hospital) with a

diagnosis of severe malaria. After review by study physicians, 393 patients met

published Cambodian severe malaria case definitions and were considered to be

‘probable severe malaria cases’. 217 P. falciparum (81.9%), 33 P. vivax (12.4%);

and 15 documented mixed infections (5.7%) positive for both P. falciparum and P.

vivax. In patients who met the severe malaria case definition (all age groups), the

most common clinical features included prostration (68%), impaired consciousness

(65%), and respiratory distress (48%), and all three were associated with a

substantially increased risk of mortality in a univariate analysis. Circulatory

collapse (15%), renal failure (27%), and pulmonary oedema (2%), though less

common, were also associated with increased mortality. In multivariate analysis,

only circulatory collapse and renal failure remained statistically significantly

associated with a higher mortality risk independent of age.

A study was conducted at the Outpatient Department of Ebonyi State

University Teaching Hospital, Abakaliki where Seventy-four (20.3%) of the

patients had Plasmodium falciparum malaria. Although all the urine parameters

were higher in the malarial patients in comparison to the control, only bilirubinuria

and urobilinogenuria were statistically significant (p <0.05). Also, bilirubinuria,

urobilinogenuria, haematuria and proteinuria were significantly (p <0.05) higher in

P. falciparum infection than in infections with other malaria species, but only in P.

falciparum infection, bilirubinuria and urobilinogenuria were significantly (p

<0.05) higher at higher parasitaemia

Kaushik R et al conducted a study at a referral hospital in Uttarakhand, where

acute kidney injury (AKI) occurred in 63 patients (32%), with maximum RIFLE

class R(Risk), Class I (Injury) and class F (Failure) in 27 (43%), 23 (37%) and 13

(21%) patients, respectively. AKI was associated with oliguria/anuria (48%),

anaemia (70%), thrombocytopenia (84%), hepatic dysfunction (48%),

gastrointestinal manisfestations (33%), ARDS (14%), cerebral malaria (6%), DIC

(8%), and shock (11%). Patients with maximum RIFLE class R, I and F had

mortality rates 3.7%, 4.3%, 30.7% respectively.

Thrombocytopenia and platelet dysfunction is the two most important changes

seen in malarial infection.

The mechanism of thrombocytopaenia in malaria could be due to peripheral

destruction and consumption by disseminated intravascular coagulation(DIC).

Thrombocytopenia is seen 40-90 percent of patients infected with P. Falciparum

infection in India.

The above percentage being obtained from 2 studies, one done in a tertiary care

hospital to study the clinical profile of Falciparum malaria on 158 consecutive

cases of Falciparum malaria, and the other study being done on 162 patients

including both Vivax and Falciparum malaria infected cases, to study

thrombocytopaenia and prolonged bleeding time in patients with malaria.

Erythrocytes containing mature parasites may activate the coagulation cascade

directly and cytokine release is also procoagulant.

Malaria is a protozoal disease caused by infection with parasites

of genus Plasmodium and transmitted by infected female Anopheline

mosquito. The various host factors influencing malaria transmission

are age, sex, race, socio-economic status, housing, occupation and

immunity. Environmental factors like season, temperature, humidity,

rainfall, and altitude also influences the malaria transmission. The

severity of the malaria is determined by (1) the species of infecting

parasite, (2) the age and physiological status, (3) Associated host

genetic factors. Severe complicated malaria is most commonly seen in

P.falciparum infections, followed by infection due to P.vivax.

Severe malaria is defined according to the WHO guidelines. The

presence of one or more of the following clinical or laboratory

features classifies the adult patient as suffering from severe malaria.

Clinical features like a) impaired consciousness or unrousable coma,

b) prostration (generalized weakness so that the patient is unable to

walk or sit up without assistance), c) multiple convulsions (>2

episodes in 24hours), d) deep breathing, respiratory distress (acidotic

breathing), e) circulatory collapse or shock (systolic BP <70mmHg), f)

clinical jaundice plus evidence of other vital organ dysfunction, g)

hemoglobinuria, h) abnormal spontaneous bleeding, i) pulmonary

edema (radiological). Laboratory findings like a) hypoglycemia (blood

glucose <40mg/dl), b) metabolic acidosis (plasma bicarbonate

<15mmol/l), c) normocytic anemia (Hb <5g/dl, packed cell volume

<15%), d) hemoglobinuria, e) hyperlactataemia (lactate >5mmol/l), f)

renal impairment (serum creatinine >3mg/dl), g) hyperparasitemia

(2%/100,000/μl in low intensity transmission areas or >5% or

250,000/μl in high intensity transmission areas).

Thrombocytopenia by definition is an abnormally low amount of

platelets, less than 1,50,000 per microliter of blood. It is sometimes

associated with abnormal bleeding. It results from various factors like

platelet activation, splenic pooling, dyspoietic process in the marrow

with diminished platelet production and reduced life-span due to

antibody and cellular immune responses.3-4 UM jadhav et al in

their study have found Thrombocytopenia is not a distinguishing

feature between type of malaria but severity of thrombocytopenia

differ between the type of malaria.

Splenomegaly is present in 70-80% of patients with malaria.

Both spleen rate and average enlarged spleen are useful indicators of

the intensity of malaria transmission in the community.3 lamb et al in

their study have found in vivo ultrasound measurement of splenic

length with the patient in right lateral decubitus position correlates

well with splenic volume measured by CT scan.5 Splenic length is less

than 12cm in 95% of the normal adult population

A study was conducted by Krishna ChV et al to assess the clinical characteristics

of acute renal failure (ARF), determine oxidative stress as well as to predict the

outcome in patients with severe falciparum malaria (FM), which included a total of

75 subjects; there were 25 adult patients with acute severe FM and ARF, 25 adult

patients with uncomplicated FM without ARF, and 25 age- and sex matched

healthy subjects as controls. In patients with severe FM and ARF, renal failure was

non oliguric in 28% and oliguric in 72%. The average duration of renal failure was

10.53+4days. 60 % recovered and 40% died. All patients with non-oliguric

presentation recovered. The Acute Physiology Age and Chronic Health Evaluation

II (APACHE II) score, Sequential Organ Failure Assesment (SOFA) score, and

Acute Tubular Necrosis-Individual Severity Index (ATN-ISI) score were all

significantly higher in the expired group when compared to the survivor group.

Kaplan-Meir survival analysis showed that survival was low in patients with

delayed hospitalization and longer duration of symptoms

STATEMENT OF THE PROBLEM

“A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE

REGARDING PREVENTIVE MEASURES OF MALARIA AMONG ADULT

WITH A VIEW TO DEVELOP HEALTH EDUCATION MODULE”

Malaria control and interventions have been implemented and in the recent

past and intensified as an effort to attain the World Health Assembly, Roll Back

Malaria, and Millennium Development universal targets with the aim of reducing

and interrupt disease transmission in sub Saharan Africa. Kagera Region is a

malaria endemic area in which malaria control measures such as the use of

Artemisinin combined therapy (ACT), the use of insecticide treated bed nets

(ITNs), indoor residual spraying of insecticide (IRS), and Intermittent Preventive

Treatment (IPTp) for pregnant women and children have been implemented.

Despite of all these efforts yet the overall prevalence of malaria infection remains

high among the underfive children: 49-53.3%, (Mboera et a., 2006) study done in

Muleba District. This verifies that there could be several reasons for this situation

including the deficiencies in the Health system that leads to lack of access to

malaria control interventions and low effectiveness of these interventions than

expected. Thus it is very essential that operational research is conducted to

identify the gaps. Therefore this work involves a community approach first to

confirm the prevalence of malaria in under-fives, coverage of ITNs, IRS as well

assessing of malaria prevalence among the under-five children, determining the

coverage of ITN use among community members, as well as assessing the factors

(socio-economic, physical, environmental, demographic factors) associated with

malaria prevalence in Muleba district.

RATIONALE FOR THE STUDY

Despite of the availability of the malaria control measures and intervention,

the morbidity and mortality in under-fives is still unacceptably high. (MoH, 2006).

This study is then designed to investigate the changing epidemiological data of

malaria. The collected data will provide the understanding on the factors that

influence the high prevalence of malaria parasite among the under five year‘s

children in Muleba District. The information that will be collected will be an

essential component in the effectiveness of Malaria control and elimination

interventions that are currently being scaled up hence it will be used to realign the

effectiveness of Malaria control measures so as to effectively reduce malaria

burden and achieve elimination.

RESEARCH QUESTIONS

1. What is the prevalence of malaria parasitemia among the under-five years in

the Community

2. What are the factors contributing to the prevalence of malaria among the under-

five In Muleba district

3. What is the coverage of ITN use among the community members

4. What is the coverage of IRS in the households in Muleba.

OBJECTIVES OF THE STUDY

1. To assess the knowledge regarding preventive measures of malaria among

the adults .

2. To develop health education module regarding preventive measures of

malaria among adults .

3. To find out association between knowledge regarding preventive measures

of malaria among adults, with selected demographic variables.

HYPOTHESIS

Hypothesis is a statement of predicted relationship between two or more

variables in a research study.

There will be a significant association between the knowledge score of

adults on the preventive measure of malaria and selected variables such as age ,

religion, education , monthly income , drainage system and environment.

OPERATIONAL DEFINITIONS:

Knowledge : It refers to the knowledge regarding

preventive measures of malaria among the adults.

Preventive measures : It is primary measure to prevent the malaria.

Assess : It refers to statistical measure of knowledge

on prevention of malaria among adults of rural

village using structured knowledge of

questionnaire.

Adults : It refers to the people of both the sex in the

age group of 20 to 59year living in nandoor ,

Gulbarga district.

Health education module: It refers to sound information regarding malaria its

causes , signs and symptoms, Management and its

prevention.

8. MATERIALS AND METHOD

8.1 SOURCE OF DATA

The research approach adopted for this study is a descriptive approach.

8.2. MATHOD OF COLLECTION OF DATA

SAMPLING CRITERIA:

Inclusion criteria:

The study includes adult people, who are,

1. Available at the time of study.

2. Willing to participate in the study.

3. Can understand Kannada and Hindi.

Exclusion criteria:

The study excludes adults people who are ,

1. Not willing to participate in the study.

2. Cannot understand Kannada and Hindi.

3. Not available at the time of study.

4. Vision and hearing problems.

METHODOLOGY

Study Design

The study design was a community based descriptive quantitative cross-sectional

household survey which was conducted between April and May, 2012 in four

selected villages

Description of the Study Area

This study was conducted in Kagera region, with a focus on Bareilly district.

Bareilly district was selected purposively as it is one on malaria endemic

areas.Bareilly District (1°45'N, 31°40'E) is in the North-western part of Tanzania

with an area of 10,739 km2 , of which 62.0% consists of Lake Victoria. Most

parts of the district lie at 1200-1500 m above sea level. Administratively the

district has 5 divisions, 31 wards, and 134 villages. It has a population of 425,172

people with 85,035 (20%) being children under the age of five years with the

majority being the Haya. The district has 36 health facilities, 3 of them being

hospitals (Rubya, Kagondo and Ndolage). Others are health centres (4) and

dispensaries (29). The district has two rain seasons which occur in March - June

and September-December during which malaria transmission peaks. Agriculture

is the main economic activity in the Bareilly district. The main food crops grown

include banana and beans, while less important ones include maize, cassava,

sorghum, groundnuts, sweet potatoes, rice plant and yams. Cash crops include

coffee, cotton, and tea. Fishing is another important activity, particularly for

villages adjacent to the Lake Victoria shore; e.g., Nshambya village in Bareilly

district district.

Health information:

Bareilly district is known to be a malaria epidemic prone area with unstable

transmission of varying seasonality. The highest peak of malaria transmission is

usually reached between May - July and November-January, which results from

proceeding rain seasons The first most devastating malaria epidemic occurred in

1997/98 following the EL- Nino rains. The district experienced another malaria

epidemic in recent years (2006). The government responded to the epidemic by

changing the first line antimalarial drug from sulfadoxine-pyrimethamine to

artemether-lumefantrine in Bareilly district. This was followed by introducing of

indoor residual spraying in 2007. Three hospitals and two health centers that are

found within Bareilly District, with inpatient facilities saw malaria-related

admissions and death rates in children under five years of age in 2006 and 2010

drop dramatically from 145 to 23 per 1000 (84% reduction) and from 42 to 5 per

10 000 (89% reduction), respectively. IRS results in Bareilly district were

impressive. An average of 100 000 house structures were sprayed per round in the

selected areas up to 2009 and over 200 000 house structures between 2009 and

2011, with spray coverage of targeted structures exceeding 95%.(NMCP,-country

report,2012) In the transmission season of 2011 (May-July) a number of health

facilities reported an increased number of malaria cases compared to the previous

three years. High mosquito densities were also recorded in some foci within the

district. Several factors were associated with this increase: acute ACT stock-outs

in first level health-care facilities, evidence of decreased susceptibility to the

insecticide used for IRS in localized areas, suboptimal net distribution in some

communities, and low reported net use. This event demonstrates the risk for

malaria resurgence in areas where it has been successfully controlled. %.(NMCP,-

country report,2012)

Study Population

The study population was divided into two groups: (1) under fives who were

checked for malaria parasites using the mRDT, (2) Head of

households/mother/guardians with underfive year‘s children or their

representative when the head of households was not around at the time of the

study

Sampling method

Random sampling design was employed as the sampling method.

Sampling Procedures

Study villages were selected using a multistage random sampling procedure and a

cluster sampling procedure as the final stage. Selection was made with the

assistance of village and sub village heads. In the first stage, names of divisions

were obtained from the office of DMO where by two divisions were selected

randomly out of the five division found in Bareilly district. Out of the randomly

selected divisions one ward from each division was selected randomly. A ward is

an administratively demarcated area below the district level, which may comprise

three to five villages (rural) In the third stage a list of villages found in each ward

were listed from records obtained from the district medical officer's office and

randomly two villages were selected In the fourth stage, out of the two randomly

selected villages, two sub-villages were randomly selected making a total of four

sub villages. From these list two divisions namely Bareilly and Kimwani were

randomly selected. Out of the randomly selected division two wards were

randomly selected namely Gwanseri and Kasharunga wards. Villages namely,

Kasheno, Nshambya, Nkomero , Kiteme were randomly selected. Another four

sub-villages were randomly selected from a list of randomly selected villages

namely Kimeya, Byantanzi, Kaina Kasheno, making a total of four sub villages.

With the assistance of sub village heads as well as the village health care workers,

a list of all household with under fives was made from which 16 to 20 households

per sub village were randomly selected to give an overall sample size of 391 study

participants which was considered sufficient for the study. In the fourth (final)

stage, level of parasitemia among the under-five children in the selected

households were ascertained during surveys using a rapid diagnostic test

(mRDTSD/bioline) with the aid of a well trained laboratory technician. Consent

to draw blood from the children was obtained from their parents/guardian.

Data Collection Method

A structured and pre-tested questionnaire was used to collect information on

sociodemographic factors, knowledge about the transmission and prevention of

malaria, utilization and coverage of ITNs were administered to the 391 eligible

participants, whereby every head of the selected household either female or male

present at home was interviewed in Kiswahili language.

Parasitological based

Presence of parasitemia among the under-five children was ascertained during

surveys using a rapid diagnostic test (mRDT) with the aid of a well trained

laboratory technician. Consent to draw blood from the children was obtained from

their parents/guardian.

Data Management and Analysis

Questionnaire was checked for errors and completeness before entry into Data base

where by summary statistics sheet was analysed using SPSS statistical software,

version 16.0 Bivariate and multivariate logistic regression analysis was employed

to examine the association between socio demographic variables and other risk

factors with malaria prevalence, and the Factors associated with malaria infection

were generated from this regression. Association between proportions of the under-

five children who we tested positive and those who were tested negative was

compared using Chi–square. A p-value of less than 0.05 was considered

significant.

Ethical Issues

Ethical clearance to conduct the study was granted by the Muhimbili University of

Health and Allied Sciences (MUHAS) research and publication committee.

Permission to conduct research was sought and granted by the Regional

Administrative Secretaries of Bareilly district. A written consent to participate was

sought from each respondent before the questionnaire was administered. Before

commencement of the study, the principal investigator and his research team

conducted meetings with local leaders and communities in all selected villages

during which the objectives of the study including procedures to be followed were

explained. Feedback to the study population was conducted in the form of

dissemination meetings after completion of the study. For those children who were

found positive were referred to the nearest health facility for the appropriate

treatment. This arrangement was done and the head of the health facility

cooperated to provide treatment.

DISCUSSION

This study was carried out in Bareilly District Council where the primary objective

of the study was to determine the prevalence, of malaria among the under-fives and

the associated factors. This study was done in mid April and this was a high

malaria season hence the high prevalence. The test was done using the mRDT

where by overall prevalence of malaria among the under-fives in the study area

was (26.3 %). The prevalence of other species (P.Vivax, P. Ovale, P.Malariae)

were also being observed higher (13%). This reflects that perhaps we are missing

other species with the microscopy. For the diagnosis of malaria, microscopy is

considered as the reference method, but expert microscopy may be lacking in both

endemic and non-endemic settings. In resource-poor endemic settings, there may

be problems related to equipment, expertise and workload, whereas I non-endemic

settings in industrialized countries, there may be a lack of routine among the

laboratory staff, resulting in low expertise. In these circumstances, the use of

malaria rapid diagnostic tests (MRDTs) can be valuable in the diagnosis of

malaria. MRDTs detect antigens specific to one or more of the Plasmodium

species. The prevalence of malaria infections found in this study was low as

compared to a previous study conducted in the same area of which indicated an

overall prevalence of malarial infection to be 49-53.3% in Bareilly district (Mboera

et al., 2006. However the findings were similar high when compared to the

findings from other studies carried out in developing countries. For example,

Malaria has the least prevalence, 27.6 percent, in children age 6 to 59 months in

the South East region of Nigeria. (Nigeria malaria fact sheet2010)

Furthermore it was observed that the prevalence of malaria was higher in Kimwani

division 50% as compared to Bareilly division of which was 17%. Several factors

were observed to be associated with the high prevalence, these includes:

socioeconomic factors, physical/environmental factors of which favors the

mosquito breeding sites as well as ineffective implementation of malaria control

measures such as the use of ITNs and IRS.

Employment status of the respondents was also being observed to be one among

the possible factor that were associated with the prevalence of malaria among the

under fives during the survey. This concurred with (Makundi EA et al (2007) who

reported that the burden of malaria is greatest among poor people, imposing

significant direct and indirect costs on individuals and households and pushing

households into in a vicious circle of disease and poverty. This was also being

observed in a study done by Wandiga SO, et al. (2006.) who stated that,

vulnerable households with little coping and adaptive capacities are particularly

affected by malaria hence they can be forced to sell their food crops in order to

cover the cost of treatment.

Furthermore, according to the study findings housing and environmental factors

such as the proximity of the house to the breeding sites/ and farming activities

were found to be associated with the prevalence of malaria. This was also being

revealed in a study done by, (Lindsay SW, et al 1993) whereby it was reported

that the relationship between malaria vector density and the distance of settlement

from a water body like river is an important indicator of malaria transmission. It

was also being supported by (Shell, 1997), who reported that Certain types of

housing may influence malaria transmission. Greater exposure to the outdoors

(lack of windows or screens, for example), may increase contact between an

individual and the mosquito vector. According to the findings of the study, the

concept of using of ITNs was considered as one of the protective factor against

the mosquito bite; hence reduce the prevalence of malaria among the under-fives.

This was supported by the MoHSW (2006) report, which stated that Insecticide-

treated mosquito nets (ITNs) used for protection against mosquito bites have

proven to be a practical, highly effective, and cost-effective intervention against

malaria.

Despite the fact that the use of ITNs was considered as one of the protective

method, It was further being identified that the prevalence of malaria among those

who were not using the ITNs was observed high as compared to those who were

using: in Kimwani division the 70% of the surveyed households were not using

the Insecticide treated Nets Selective indoor residual spraying (IRS) remains one

of the key strategies of the NMCP, though primarily used for epidemic prevention

and response. Indoor residual spraying with insecticide has been shown to be

highly effective as a malaria control measure in reducing the incidence of malaria

infections and deaths in a number of settings. (Oaks SC Jr, et al 1991). However

the study findings supported that IRS, was associated with protection from

parasitemia in both bivariate and multivariate analysis, it was also being observed

that many of the residents who were residing in Kimwani division were migrants

who were coming for the purpose of cultivating rice plant. Due to the issue of

settlement then people were found staying in places which were not sprayed by

IRS hence this increased the chance of mosquito bites and thus the high

prevalence. Taken together, the results presented here illustrates that: ITNs use,

IRS, parents/guardians education status, economic status; physical/environmental

factors are the predictive factors of the prevalence of malaria among the under-

fives.

STUDY LIMITATIONS

1. To some of the houses no physical check was done at household levels

regarding ownership of LLITNs

2. The use of LLITNs in the previous night may not reflect the actual regular use

3. The issue of asking parents/guardian verbally whether their children have

experienced an episode of fever within the past six month to determine the

prevalence of malaria.

CONCLUSION

It can be concluded that bareilly district specifically kimwani divisions has the

prevalence of malaria that is more being observed among the under-fives as

compared with Bareilly Division. The higher prevalence could be the result of

several factors as explained in this study. The finding of the study reflects that if

the control measures will be implemented appropriately then the prevalence of

malaria will decrease. Carefully-coordinated surveillance and response are

required to address ongoing, low-level transmission hot spots as well as acute

outbreaks once sustained control of malaria will be eventually achieved.

RECOMMENDATIONS:

1. There is the need for a strong collaboration among major stakeholders including

the Government, District Assemblies, and Non- Governmental Organizations to

sensitize the communities on Malaria as a disease as well as developing the holistic

and effective methods for prevention and control of the disease.

2. Though the uses of IRS, LLITNs are identified as the major method of

prevention due to their availability and affordability for many households, the

implementation of these methods is still questionable. Therefore the

implementation of these methods needs to be re-assessed by concerned authorities

in order not to endanger the health of the people.

3. Efforts must be seriously made by the major players in the health sector to make

the net readily available in the communities at low prices to enable the ordinary

Tanzanians to purchase it.

4. In order to improve timeliness of treatment, the service consequently needs to be

closer to the communities especially those found in the remote and malarious

endemic areas like Kimwani/ Kasharunga village in Bareilly district.

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