Community-based Malaria Control Programme Research Articles

The use of insecticide-treated nets for reducing malaria morbidity among children aged 6-59 months, in an area of high malaria transmission in central Côte d'Ivoire

BackgroundLong-lasting insecticidal nets (LLINs) are an important tool for controlling malaria. Much attention has been devoted to determine both the effect of LLINs on the reduction of Plasmodium infection rate and on clinically-confirmed malaria cases in sub-Saharan Africa. We carried out an epidemiological study to investigate whether LLINs impact on Plasmodium prevalence rate and the proportion of clinically-confirmed malaria cases, in five villages in the district of Toumodi, central Côte d'Ivoire.MethodsFrom April 2007 to November 2008, a community-based malaria control programme was implemented in the study villages, which involved large-scale distribution of LLINs, and training and sensitization activities within the community. We determined the effect of this programme on Plasmodium prevalence rate, clinically-confirmed malaria cases and proportion of high parasitaemia rates in children aged 6-59 months through a series of cross-sectional surveys starting in April 2007 and repeated once every 6 months.ResultsWe observed a significant decrease in the mean P. falciparum prevalence rate from April 2007 to April 2008 (p = 0.029). An opposite trend was observed from November 2007 to November 2008 when P. falciparum prevalence rate increased significantly (p = 0.003). Highly significant decreases in the proportions of clinical malaria cases were observed between April 2007 and April 2008 (p < 0.001), and between November 2007 and November 2008 (p = 0.001).ConclusionsLarge-scale distribution of LLINs, accompanied by training and sensitization activities, significantly reduced Plasmodium prevalence rates among young children in the first year of the project, whereas overall clinical malaria rates dropped over the entire 18-month project period. A decrease in community motivation to sleep under bed nets, perhaps along with changing patterns of malaria transmission, might explain the observed increase in the Plasmodium prevalence rate between November 2007 and November 2008.

Reduced paediatric hospitalizations for malaria and febrile illness patterns following implementation of community-based malaria control programme in rural Rwanda

BackgroundMalaria control is currently receiving significant international commitment. As part of this commitment, Rwanda has undertaken a two-pronged approach to combating malaria via mass distribution of long-lasting insecticidal-treated nets and distribution of antimalarial medications by community health workers. This study attempted to measure the impact of these interventions on paediatric hospitalizations for malaria and on laboratory markers of disease severity.MethodsA retrospective analysis of hospital records pre- and post-community-based malaria control interventions at a district hospital in rural Rwanda was performed. The interventions took place in August 2006 in the region served by the hospital and consisted of mass insecticide treated net distribution and community health workers antimalarial medication disbursement. The study periods consisted of the December–February high transmission seasons pre- and post-rollout. The record review examined a total of 551 paediatric admissions to identify 1) laboratory-confirmed malaria, defined by thick smear examination, 2) suspected malaria, defined as fever and symptoms consistent with malaria in the absence of an alternate cause, and 3) all-cause admissions. To define the impact of the intervention on clinical markers of malaria disease, trends in admission peripheral parasitaemia and haemoglobin were analyzed. To define accuracy of clinical diagnoses, trends in proportions of malaria admissions which were microscopy-confirmed before and after the intervention were examined. Finally, to assess overall management of febrile illnesses antibiotic use was described.ResultsOf the 551 total admissions, 268 (48.6%) and 437 (79.3%) were attributable to laboratory-confirmed and suspected malaria, respectively. The absolute number of admissions due to suspected malaria was smaller during the post-intervention period (N = 150) relative to the pre-intervention period (N = 287), in spite of an increase in the absolute number of hospitalizations due to other causes during the post-intervention period. The percentage of suspected malaria admissions that were laboratory-confirmed was greater during the pre-intervention period (80.4%) relative to the post-intervention period (48.1%, prevalence ratio [PR]: 1.67; 95% CI: 1.39 – 2.02; chi-squared p-value < 0.0001). Among children admitted with laboratory-confirmed malaria, the risk of high parasitaemia was higher during the pre-intervention period relative to the post-intervention period (age-adjusted PR: 1.62; 95% CI: 1.11 – 2.38; chi-squared p-value = 0.004), and the risk of severe anaemia was more than twofold greater during the pre-intervention period (age-adjusted PR: 2.47; 95% CI: 0.84 – 7.24; chi-squared p-value = 0.08). Antibiotic use was common, with 70.7% of all children with clinical malaria and 86.4% of children with slide-negative malaria receiving antibacterial therapy.ConclusionThis study suggests that both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts. Additionally, this study highlights the problem of over-diagnosis and over-treatment of malaria in malaria-endemic regions, especially as malaria prevalence falls. More accurate diagnosis and management of febrile illnesses is critically needed both now and as fever aetiologies change with further reductions in malaria.

Community participation in malaria control in Tigray region Ethiopia

During the Ethiopian civil war from 1974 to 1991, the Tigrean People's Liberation Front established a primary health care system in Tigray in which community residents helped to plan and implement health services through health committees and community health workers (CHWs). To strengthen and update this systems, a Community-Based Malaria Control Programme was initiated in 1992. The primary objectives of the Programme are to reduce malaria morbidity and mortality and to prevent malaria in pregnant women through early diagnosis and treatment of cases, chemoprophylaxis during pregnancy, and vector control by environmental management. A secondary objective is to introduce a cost-sharing scheme for eventual development of a village revolving fund. A total of 681 volunteers chosen by their communities have received malaria training and serve a rural population of 1,682 319 (CHW/population ratio 1:2, 500). The principal success of the programme at this stage is that a significant proportion of the rural population at risk for malaria is now being treated at the village level. During the last major transmission season from September through November 1993, each CHWs treated a mean of 45 178 clinical malaria cases per month. Under-utilization of treatment services by woman and children under 5 years and low chemoprophylaxis coverage of pregnant women have been documented. After focus group discussions with community members and CHWs to identify the reasons for these problems, changes in programme policies were made to improve coverage of these groups. Since 1992, considerable progress toward meeting programme objectives has been made, and continued evaluation will allow for interventions that should further strengthen the malaria control efforts in the region.

Local terminology for febrile illnesses in Bagamoyo District, Tanzania and its impact on the design of a community-based malaria control programme

This paper reviews results of several ethnographic studies that have examined the issue of local terminology for malaria in Africa, then presents findings from an on-going study in Bagamoyo District, Tanzania. The study used a mixture of qualitative and quantitative interview methods to examine local perceptions of malaria and malaria treatment practices. Although the local term homa ya malaria or malaria fever appeared on the surface to correspond closely with the biomedical term malaria, significant and often subtle differences were found between the two terms. Of perhaps greatest importance, common consequences of malaria in endemic areas such as cerebral malaria in young children, severe anaemia and malaria in pregnancy were not connected with homa ya malaria by many people. A set of guidelines are described that were used to determine how best to promote acceptance and use of insecticide-impregnated mosquito nets, given these results. It is demonstrated that the position of the term used to denote malaria in the local taxonomy of febrile illnesses has important implications for the design of health education interventions.

C-reactive protein and haptoglobin in the evaluation of a community-based malaria control programme

When cross-sectional surveys are used to evaluate malaria intervention programmes in the community, the prevalence of morbidity is difficult to assess because of the fluctuating nature of malarial fever. We have therefore investigated the impact of bed net usage on 2 surrogate markers of malarial morbidity: (i) elevated C-reactive protein (CRP) (>8 mg/L) plus detectable parasitaemia, as an indicator of malaria-induced acute-phase response; and (ii) reduced haptoglobin levels (<180 mg/L), which in this population indicates malaria-induced intravascular haemolysis. Among 1505 Gambian children 1–5 years old, examined on a single occasion at the end of the malarial transmission season, 5% had parasitaemia plus fever, while 24%, had parasitaemia plus elevated CRP, and 35% had low haptoglobin. The proportion of children who had parasitaemia plus elevated CRP was significantly lower among those who had slept under insecticide-treated bed nets than among those who did not use a bed net (16% vs. 34%, P < 0.003), and the proportion with low haptoglobin differed similarly (24% vs. 49%, P < 0.003). Use of an untreated bed net had a weaker effect on both indices (22% had parasitaemia plus elevated CRP, 34% had low haptoglobin). CRP and haptoglobin are simple and inexpensive to measure in large numbers of people, and these results suggest that they could be useful for the assessment of malaria intervention programmes.

Demographic findings relevant for health care planning and evaluation collected through a malaria control project in the Kivu Mountains, Zaire

Population studies were conducted in the margin of a community based malaria control programme in the Katana Health zone, in the Eastern part of Zaire. The reported findings are based on prospective registration of vital events from March 1986 through February 1987. At mid term 28.083 people were covered. The age and sex structure of the population was typical for tropical Africa, apart from an excess of males to females after the age of 64. The mean age at marriage was 21.2 years for women and 25.6 years for men. 89% of women did not complete a single year of formal education. The crude fertility rate was 250‰ and total fertility 8.3 children. The infant mortality rate and the child mortality quotients attained 130‰ and 183‰ respectively. The crude death rate was 23 per 1000 and the natural population growth rate 31‰. Due to a net out-migration of 28‰ the zone's population remained, however, virtually stable. The latter observation questions the purported role of demographic pressure as a key determinant of the region's slow socio-economic development. The other findings provide valuable baseline and background information for planning and evaluating health-related activities.

Consumption of chloroquine phosphate provided for treatment of malaria by volunteer village health workers in Saradidi, Kenya.

A community-based malaria control programme in Saradidi, Kenya provided chloroquine treatment for malaria in each village beginning in May 1982. Malaria was holoendemic in Saradidi. Treatment was provided by volunteer community health workers chosen and supported by the village. Consumption of the drug and characteristics of persons treated were recorded. Between 1 September 1982 to 31 August 1983, 40,649 treatments with chloroquine were given to village residents. The treatment rate per person in the mid-year population was 1.24. However, at least 41.8% of the mid-year population of 32,650 did not receive a single treatment. Multiple treatments were given to 50.5% of persons treated at least once and 13.4% of 13,879 persons treated at least once received five or more treatments during the year. Consumption patterns were not random: they were higher in females, in persons above 30 years of age and in the area with greater community organization and community participation. There is need to ascertain the reasons why so large a proportion of the population never received a single treatment in this highly malarious area and why adults who should not have had a high frequency of clinical malaria were treated so often. Nonetheless, the results demonstrate that volunteer community health workers can effectively provide treatment for malaria.

Impact on mortality and fertility of a community-based malaria control programme in Saradidi, Kenya.

Mortality and fertility rates were measured from 1981 to 1983 by prospective registration of vital events as part of a community-based malaria control and health development programme in Saradidi, Kenya. There was no obvious effect of providing chloroquine phosphate for treatment of malaria in each village on mortality or fertility rates. Crude death rates were 13.1 in the year before intervention (1 May 1981 to 30 April 1982) and 12.3 after intervention (1 September 1982 to 31 August 1983). Neonatal mortality increased from 36.8 per 1000 live births pre-intervention to 49.1 during intervention. There was a slight decline in post-neonatal (one to 12 months) mortality (72.8 to 67.0) and a significant drop in early childhood mortality (25.2 to 18.2). The change in mortality rates in these two age groups were fully explained by a high rate of measles mortality in the pre-intervention period. Measles accounted for 35.7% of 284 reported deaths in infants one to 12 months of age and for 40.9% of 230 deaths in children one to four years old. There was little change in reported malaria-specific mortality rates in infants and young children most likely because of a high level of chloroquine use for treatment of presumptive illness. Perinatal mortality by area ranged between 60.4 and 81.3 pre-intervention to 79.5 to 97.2 after the control programme was instituted. Crude birth rates by area remained stable at about 40 and general fertility rates were about 200. Both pre-intervention and during intervention infants were significantly more likely to have died without medical consultation than children one to four years. However, 79.2% of 284 infants and 90.7% of 193 children died in spite of having consulted a health worker prior to death. The data suggest that a measles vaccine programme would significantly reduce mortality rates in infants and young children. The fact that the majority of infants and young children died in spite of receiving medical attention indicates both the inadequacy of curative medical services in this high mortality setting as well as the necessity for promoting preventive health measures.

Community-based malaria control in Saradidi, Kenya: description of the programme and impact on parasitaemia rates and antimalarial antibodies.

A community-based malaria control programme initiated in Saradidi, Kenya in 1982 is described. Antimalarial treatment provided by volunteer community health workers was made available in each village. Malaria was holoendemic. Parasitaemia rates by age were high and did not change after the control programme began. Plasmodium falciparum was the most common species and was present alone or mixed in 98.2% of 8105 infections. Virtually all (98.5%) of 2040 blood samples collected in May 1981 were positive (reciprocal titre greater than or equal to 80) to P. falciparum by the indirect fluorescent antibody (IFA) test. Seropositivity rates to P. falciparum in the IFA test or the enzyme-linked immunosorbent assay (ELISA) were high in all age groups and did not change significantly in longitudinal surveys or in a cohort of children zero to nine years old followed at intervals. While the malaria control programme was successful in bringing treatment to each village, malaria prevalence was not reduced. Parasitologic and serologic studies alone were not adequate to describe the impact of the community-based malaria control programme in Saradidi. Morbidity and mortality rates caused by malaria can decline, significantly improving the health of the population, in the absence of any decrease in parasitaemia rates.

Symptoms associated with common diseases in Saradidi, Kenya.

A community-based malaria control programme was initiated in Saradidi, Kenya. One factor determining the utilization of treatment would be the symptoms felt to be diagnostic of malaria. The 12 most common diseases and 29 most common symptoms were identified by community members. Thirty-six randomly selected women were interviewed to determine association of the common diseases and symptoms; nine women were aged 15 to 29 years, nine women were 30 to 40 years, nine were 45 to 59 years and nine were 60 years or more. Women 60 years and older recognized a higher proportion of the diseases (P less than 0.0005) when compared with the other women of other ages. More than 90% of the women associated headache, fever, vomiting, joint pain, loss of appetite, tiredness and death with malaria. Measles and influenza were distinguished from malaria by rash and mouth ulcer for measles and by 'runny nose' and 'sneezing' for influenza. Analysis by average linkage hierarchical clusters revealed that malaria, influenza and measles were distinguished readily. The results suggest that if people in Saradidi do not obtain treatment from community health workers, it is not because they do not recognize the clinical symptoms of malaria.

Changes in sources of treatment occurring after inception of a community-based malaria control programme in Saradidi, Kenya.

To determine the changes in source of antimalarial treatment and perceptions about malaria after the initiation of a community-based malaria control programme in Saradidi, Kenya, two identical surveys were carried out; one in March 1982 (before the programme began in May 1982) and the other in December 1984. Three areas were involved: areas A and B had antimalarial treatment provided by village health helpers (VHH's) and area C had VHH's who did not provide treatment. Two groups of randomly selected women age 15 to 59 years were interviewed: 45 in survey 1 and 92 in survey 2. A decided change in the source of malaria treatment was observed. In the first survey, 52.9% of the respondents from areas A and B combined purchased antimalarial medicine from shops; other sources were government health facilities, mission clinics, and the Saradidi community clinic. By the second survey, 85.2% of the respondents in areas A and B obtained treatment from the VHH's; no significant change occurred in area C. In both surveys the leading reasons given for people purchasing drugs from shops was that the distance to health facilities was great, that no transport was available and that shops were open when emergencies occurred. The shopkeeper frequently advised which drug to take and the dosage as well as selling the drugs. For family illnesses of unknown aetiology most people (82.2% in survey 1 and 97.8%, in survey 2) went to a hospital or clinic. These results demonstrate that the malaria control programme in Saradidi has influenced both the source of antimalarials and the attitudes people have about malaria. In Saradidi, Kenya people chose to obtain antimalarial treatment and advice from community health workers.

Usage of community-based chloroquine treatment for malaria in Saradidi, Kenya.

A survey was done in June 1983 in Saradidi, Kenya, one year after the inception of a community-based malaria control programme to determine if people were obtaining malaria treatment from volunteer village health helpers (VHH's) chosen by the community. Ten of 36 villages were randomly chosen. From these ten villages, 100 households were randomly selected and 222 people ten years of age or more were interviewed; 113 (50.9%) had a history of malaria in the previous two weeks and 82 (72.6% of 113) had taken medicine for malaria in that period. Of these 82, 51.2% obtained drug from the VHH, 28% purchased it from a shop, 12.2% from a health facility, 4.9% from family members and 3.7% from a private practitioner or a shop outside Saradidi. Reasons given for not obtaining treatment from the VHH's among the 40 people who went elsewhere for treatment included: the VHH was not at home when needed (35%); the VHH had no drugs (22.5%); the patient was too sick for the VHH to treat (10%); had drugs already in the home (10%); 'not registered' with VHH (10%); VHH 'no good' (7.5%); and more 'convenient' to go elsewhere (5%). Similar results found on questioning the mother were obtained for 103 children under nine years old in these households; 67 (65.0%) children had a history of malaria in the previous two weeks and 59 (88.1%) of these 67 children had received antimalarial treatment. The VHH was the principal source of treatment (50.8% of 59), followed by health facilities (20.3%) and shops (18.6%).(ABSTRACT TRUNCATED AT 250 WORDS)