A HOSPITAL BASED STUDY OF MALARIA IN NDIEGORO BY

A HOSPITAL BASED STUDY OF MALARIA IN NDIEGORO
COMMUNITY, ABA SOUTH L.G.A. ABIA STATE.
BY
UMEH, JUDE MMADUKA
REG. NO.M.Sc/2007586009P
DEPARTMENT OF PARASITOLOGY AND ENTOMOLOGY
NNAMDIAZIKIWEUNIVERSITY, AWKA
ANAMBRA STATE – NIGERIA
SUPERVISOR:
PROF.(MRS.)C.I.ENEANYA
MAY-AUGUST,2009
2
TITLE PAGE
A HOSPITAL BASED STUDY OF MALARIA IN NDIEGORO
COMMUNITY, ABA SOUTH L.G.A., ABIA STATE.
A RESEARCH PROJECT PRESENTED TO THE DEPT. OF
PARASITOLOGY AND ENTOMOLOGY,
NNAMDIAZIKIWEUNIVERSITY, AWKA,
ANAMBRA STATE, NIGERIA
BY
UMEH, JUDE MMADUKA
REG. NO.M.Sc/2007586009P
IN PARTIAL FULFILMENT OF THE REQUIREMENTS
FOR THE AWARD OF MASTER OF SCIENCE (M.Sc.)
IN PARASITOLOGY AND ENTOMOLOGY
SUPERVISOR: PROF. (MRS.) C. I. ENEANYA
MAY-AUGUST, 2009
3
CERTIFICATION
This is to certify that this research project work was done by
Umeh, Jude Mmaduka. in the department of Parasitology and
Entomology, NnamdiAzikiweUniversity, Awka, Anambra State,
Nigeria.
Sign_____________________
Prof. (Mrs.) C. I. Eneanya
(Supervisor)
Sign___________________
Dr. N.A. Ozumba
(Head of Dept.)
4
DEDICATION
This work is dedicated to God, the Almighty, for granting me
good health throughout the period of my studies in this University.
5
ACKNOWLEDGEMENT
I am immensely grateful to my project supervisor, Prof.
(Mrs.) C.I. Eneanya
for
her
motherly advice, constructive
criticisms and painstaking efforts for the realization of this
work.
Special thanks go to the management and staff of Victory
Christian
South
L.G.A.
immense
effort
Hospital
of
for
support
located
in
Permission
of
the
Mr. C. Utazi
Ndiegoro
to
use
laboratories
of
the
Community, Aba
the
hospital
and
technologists. The
Statistics
Department,
NnamdiAzikiwe University, Awka is highly appreciated for
assisting me in the use of the Graph pad Instat Demo
software package for the analysis of my results.
Finally I remain ever grateful to my entire family for
their co-operation and concern.
6
TABLE OF CONTENT
Title page
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Certification
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Dedication
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Acknowledgement
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Table of content
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List of tables
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List of figures
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Abstract
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1
1.2Aims and objectives
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Chapter One
Introduction
Chapter Two
Literature Review
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2.1
Geographical distribution of malaria
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2.2
Epidemiology of malaria
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2.2.
Environmental factors
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5
2.2.2 Vectorial factors
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2.2.3 Host factors
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2.3
Studies on the prevalences of malaria
7
2.4
Transmission of malaria
12
2.5
Life cycle of malaria parasite
13
2.6
Pathogenesis and Pathology of malaria
16
2.7
Diagnosis of malaria
16
7
Chapter Three
3.0
Materials and Method ..
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3.1
Study areas
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3.2
Study subject
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3.3
procedure ..
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3.4
Qualitative data collection ..
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3.5
Analysis of results .. .. ..
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Chapter Four
Results
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Summary and Recommendations ..
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Chapter Five
Discussion
Chapter Six
6.1
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References
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38
Questionnaire
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Appendices
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54
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LIST OF TABLES
Table 1:
Age prevalence of malaria
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Table 2:
Sex prevalence of malaria
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Table 3:
Help-seeking behaviour of the respondents
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28
Table 4:
Preventive measures adopted
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28
Table 5:
Methods of malaria treatments used
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28
Table 6:
Educational background and method of treatment
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29
LIST OF FIGURES
Figure 1:
Geographic Distribution of Malaria
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4
Figure2:
The Life Cycle of Malaria
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19
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9
ABSTRACT
The
study surveyed the prevalence of malaria as well as management practices
adpted in Ndiegoro community, Aba South L.G.A., Abia state between May and
August 2009. Blood samples of 300 individuals who attended local hospital were
examined using Giemsa stained thick and thin films, One hundred and fifty two
(152) persons (51%) were infected with Plasmodiumfalciparum . The age group 0-5
years ( 74.3%) had the highest prevalence, while the age group 36-45 years ( 40.0%)
recorded the lowest prevalence in the study. Males ( 58.7%) were statistically more
infected than females ( 43.3%) ( p< 0.05 ). Structured questionnaire were also
administered to obtain their management practices. On the help-seeking behavior
of the respondents more persons (63.4%)
in the age group 0-15 years attend
laboratories for diagnosis more often than those in the age group 16> (36.6%). More
of the respondents resorted to patent chemist (27.6%) for treatment purposes. Visit
to hospitals for treatment was the least patronized (12.0%). Some of the
respondents combined more than one methods in their treatment for malaria. The
use of prophylactic drugs( 6.0%) and insecticide treated nets( 1.8%) were the least
preventive measures adopted by the respondents. This was due to the financial constaint
and non-awareness of them. Malaria still remained a public health problem in Nigeria and
data on its precise prevalence in some communities has remained unidentified.
CHAPTER 1
MALARIA
INTRODUCTION:
Malaria is a life-threatening disease of man caused by parasite of the genus
Plasmodium, which is transmitted from person to person, through the bite of
infected female Anopheles mosquitoes. It is a killer and debilitating disease and
remains a formidable health and socio-economic problem in the world (Nebeet al,
10
2002). Jaine and Michael (1990) described it as the leading cause of death in the
developing world. The World Health Report (2002) reported that about 90% of all
malaria deaths in the world today occur in Africa, South of the Sahara. And that
this is because majority of the infections in Africa are caused by Plasmodium
falciparum, the most dangerous of the four human malaria parasites. Anopheles
gambiae is the most effective malaria vector, the most widespread in Africa and
the most difficult to control. Global estimate on morbidity and mortality resulting
from malaria shows between 300-500 million clinical cases and between 1.5-2.7
million deaths attributed to malaria annually (Obi, 1997; Salako, 1997; WHO,
1998 and UNICEF, 2000), and an estimated one million people in Africa die from
malaria each year and most of these are children under 5 years old and women in
their first pregnancy (WHO, 2002; Sherman, 1998). NIH (2001) reported that the
number of deaths from malaria are on the increase due to insecticide resistance,
antimalarial resistance and environmental changes.
The four important species of the parasite that cause this disease are
Plasmodium falciparum.P. malariae, P ovaleand
P. vivax. Various species of
the malaria parasites such as P.falciparum and P. malariaeare reported in Nigeria
(Eneanya, 1998; Matur, et al, 2001). Anopheles gambiae, An. funestus and An.
arabiensis have been implicated for malaria transmission in Nigeria with major
impacts (Umaru et al, 1997). Scientific investigations revealed many pathological
effects of malaria on man which include varying degrees of anaemia, splenic
enlargement and various syndromes resulting from physiological and pathological
involvements of certain organs like the brain, liver and the kidneys (Adams and
Macgraith, 1985). Chukwuraet al (2003) described P. falciparummalaria as the
11
most prevalent and virulent in Nigeria, capable of causing mental apathy,
weakness and generally slowing down economic development; accounting for up
to 98% of severe cases with significant mortality and morbidity (WHO, 2000).
Malaria has been observed to keep people away from school or work thereby
affecting;
(i)
The amount they learn at school
(ii)
The quantity of food they are able to grow and
(iii)
The money they can earn (WHO, 1991). Salako (1996) and Cooker et al,
(2001) reported that malaria accounts for over (600) six hundred deaths
daily in Nigeria, especially in children less than five years of age in the
rural, peri-urban and urban settlements; with high index of child mortality
from the disease.
Mbanugo and Ejims (2000) also reported that malaria is holoendemic in many
countries and directly responsible for up to 10-25% of the infant mortality. Poor
knowledge, attitude and practice (KAP) by our people in handling malaria seems
to compound the issue of this disease in our various communities, particularly in
AbiaState. Studies in Nsukka, Enugu state by Briegeret al (1997) and in a coastal
area of Lagos state by Nebeet al (2002) confirmed that the perception of malaria
by the inhabitants were not helpful. Many believe that malaria is caused by such
factors as excessive heat, malnutrition, eating too much palm oil and other
superstitious considerations. This poor malaria perception stimulated the present
study ‘A study to determine the prevalence of malaria infection among members
of Ndiegoro community, Aba South L.G.A., Abia State., attending hospital and to
ascertain their management practices’. The outcome of the study is hopefully
12
expected to disclose some strategies for eliminating or reducing to the barest
minimum this health problem of man and enhancement of his health, generally.
1.2
AIMS AND OBJECTIVES OF THE STUDY
The aims and objectives of this study are;
 To determine the prevalence of malaria in the study area andto
document the management practices by the people in the community.
(ii)
Specific Objectives:
These are:
 To determine the prevalence of malaria with regards to age and sex
 To identify the Plasmodium species prevalent in the study area
 To document the help-seeking behavior of the people
 To document the preventive measures adopted by the people
 To document the treatment methods by the people
13
CHAPTER TWO
LITERATURE REVIEW
2.1 GEOGRAPHICAL DISTRIBUTION
P. falciparum is found mainly in the hotter and more humid regions of the world.
It is the main species found in tropical and subtropical Africa and parts of Central
America and South America, Bangladesh, Pakistan, Afghanistan, Nepal, Sri
Lanka, Southeast Asia, Indonesia, Philippines, Haiti, Solomon Islands, Papua New
Guinea and many islands in Melanesia. It also occurs in parts of India, the Eastern
Mediterranean and Middle East.Plasmodium falciparum is the most commonly
encountered species in West Africa including Nigeria (Seboxa and Snow,1997;
Mbanugo and Ejims,2000; Aribodoret al; Asianyaet al,1999)
P. vivaxis capable of developing in mosquitoes at lower temperatures than P.
falciparum, and therefore has a wider distribution in temperate and subtropical
areas. P. vivax is the main Plasmodium species in South America, Mexico, the
Middle East, India, Pakistan, Sri Lanka, Papua New Guinea and Solomon Islands.
It is also found in parts of Southern Asia, Indonesia, Philippines, Madagascar,
tropical and subtropical Africa, china and Korea.
P.malariae has a much lower prevalence than P.
falciparumand P. vivax. It
accounts for up to 25% Plasmodium infection in tropical Africa. It is also found in
India, Guyana, Malaysia and Sir Lanka. In these countries, it accounts for less than
10% of Plasmodium infections.
Plasmodium ovale has a restricted distribution and of low prevalence. It is found
mainly in West Africa where it accounts for up to 10% of malaria infections. It has
also been reported from other parts of the Far East, South East Asia and South
America.
14
2.2 EPIDEMIOLOGY OF MALARIA
The setbacks in attempts at malaria eradication have led to renewed interests in the
epidemiology of malaria. Various factors interplay to determine the two
epidemiological extremes of malaria, that is, stable and unstable malaria. Such
factors include environmental (or climatic), vectorial, parasite and host factors and
failure of control policies. Malaria not only increase malaria- specific morbidity
and mortality but also affect the general health of the population. Many malaria
epidemics coincide with periods of famine, economic meltdown, war or civil
disturbances involving impoverished populations that are often affected by other
disease as well. The greatest consequences of malaria cases in many parts of the
world stems in large part to these economic and human factors (Dick, 1985).
2.2.1 Environmental factors
The potential of the mosquito to serve as a vector depends on the ability to support
sporogony, mosquito abundance, and contact with humans, which are all
influenced by climatic and ecological factor. Temperature and mosquito longevity
are other key factors affecting the parasite’s interaction with the vector.
Development of P. falciparum requires a minimum temperature of 200C, whereas
the minimum temperature for the other species is 16 0C. Temperature also affects
the time of development in that the duration of sporogony is shorter at higher
temperatures. A shorter duration of sporogony increases the chances that the
mosquito will transmit the infection within its lifespan .Climatic factors such as;
altitude, temperature and rainfall and breeding places also affect mosquito density.
Small increases in existing low temperatures have been shown to exert a strong
effect on increased transmission of malaria (Bradley, 1993; Lindsay and Birley,
1996).In a site situated at 2000m in western Kenya, malaria cases steeped when
mean monthly temperature exceeds 18C and rainfall greater than 1500mm per
month(Malakootiet al, 1998).Wet and humid environments provide the breeding
15
sites and prolong the life of malaria vectors (Lindsay and Birley, 1996). These
optimum conditions occur through out the year in most part of Nigeria and hence
the prevalence rate is fairly constant throughout the year in both urban and rural
areas. At high altitude, prevalence rate of malaria is low and no transmission
occurs at 600 feet above sea level(Taylor and Mutambu, 1986).
2.2.2Vectorial Factors:
The Mosquito (Anopheles spp.)
These are behavioral factors and susceptibility to infection. Some species of
Anopheles are anthropophilic (prefers human blood), others zoophilic (prefers
animal blood); some prefer to bite indoors (endophagy), others outdoors
(exophagy); some prefer to rest during the day indoor(endophily), others out doors
(exophily). Malaria vectors bite between dusk and dawn and generally choose
well-oxygenated water rather than stagnant polluted pools to lay her eggs.
Anopheles gambiae, Anopheles arabiensis and Anopheles funestustransmit most of
human malaria and are all found in Africa (Besanskyet al, 2004). An. gambiae, the
most famous and significant of the three, is one of sixty anopheline mosquitoes
able to transmit malaria to humans (Budiansky, 2002). An gambiaeis the primary
malaria vector, this can be attributed, in part, to its relatively long life strong
anthropophily and endophily.Their larvae tend to develop in temporary water
bodies, such as those typically found near agricultural sites or even in flooded hoof
print (Vogel, 2002). All these characteristics combine to make An. gambiaethe
mostsuccessful vector.
2.2.3 Host Factors:
The following human factors influence the epidemiology of malaria: genetic,
immune, nutritional and behavioral.
Behavioural Factors:
16
Many elements of human behavior profoundly affect the epidemiology of malariauncontrolled urbanization; subsistence agriculture; population movements; woodgathering in the forest; open-cast mining; gem-silver and other mining,
agricultural production of cotton, sugar-cane, rubber and rice.
Behavioral patterns emerge in different communities and are influenced by
cultural, ethnic and religious backgrounds.
The introduction of electricity into rural areas has resulted in promoting late-night
outdoor activities and thus increased biting opportunities for mosquitoes.
Genetic factor
Some inherited disorders of haemoglobin such as sickle cell confer a reasonable
degree of resistance or immunity against malaria to certain groups of individuals.
It has been found that those individuals who are heterozygous for haemoglobin
(AS) suffer malaria less frequently and less severely than to normal individuals
(Olumeseet al, 1997). It has also been found that those individuals with ß –
thalassaemias are protected against malaria. In a clinic-based case control study in
Northern Liberia, sickle cell carries showed about 70% reduction in their risk of
clinical malaria while carries of ß –thalassaemias showed 50% reduction in risk
(Willcoxet al ;1983).
2.3 STUDIES ON THE PREVALENCE OF MALARIA
High prevalence of malaria has been reported in various parts of Nigeria. In a
Survey of the prevalence of Plasmodium species and common clinical symptoms
in a rural community in ImoState, Chukwuochaet al, (2008) found a 68%
prevalence
of
malaria
in
the
study
community.
They
reported
that
P.falciparum(67.8%) was the dominant parasite while P.malariae occurred in
mixed infection with both parasites at a 0.9%.
17
Ukpai and Ajoku (2001) in a hospital-based study of the prevalence of malaria in
Okigwe and Owerri areas of ImoState, reported a prevalence of 321(80.25%) out
of 400 individuals examined. Okigwe had a higher prevalence rate (85.5%) than
Owerri (75.00%). Infections with P. falciparum was the highest in the two areas
studied with 53.00% infection rate at Owerri an 60.00% infection rate at Okigwe.
Some authors have reported a significantly higher prevalence in males than
females (Obiukwu and Okwuon (2008), Ikeh and Udem (2008), Ukpai and Ajoku
(2001); Matur et al, (2001).
Studies on prevalence of malaria and management practices of the Azia
Community in Ihiala L.G. A., AnambraState, South east, Nigeria, showed a 76%
prevalence rate of malaria, all were infections of Plasmodium falciparum.
(Aribodoret al, 2004). Matur et al (2001) in a study of prevalence of malaria
parasites amongst the undergraduates of the university of Abuja reported a
prevalence rate of 121 (61%) out of 200 blood samples examined.Similarly,
Mbanugo and Ejims (2000) reported a prevalence of 233 (58.3%) out of 400
children examined for malaria parasites in Awka Metropolis, AnambraState. All
positive cases were infections of Plasmodim falciparum.
A three year study to investigate the seasonal variations in episodes of malaria
among residents in a semi-urban community in south east Nigeria, showed that
between January and December 1996, 755 (62.9%) individual had parasitaemia of
either P. falciparum or P. malariaeor both. The age-specficprevalences were:
73.8% for (0-4) years; 76.4% for (5-9) years, 67.2% for (50-59) years; 43.5% for
60 years (Eneanya, 1998.)Usip and Opara (2008), reported a malaria prevalence
of 552 (54.4%) out of 1, 012 patients attending St. Luke’s General Hospital, Anua,
Uyo State between May 2003 and April 2004. All malaria positive cases reported
were due to Plasmodium falciparum.
18
In a study on the prevailing knowledge, attitude and practices (KAP) amongst
mothers and caregivers in Aba South L.G.A., AbiaState towards malaria infection,
Ukpai and Amaechi (2008) reported a remarkable mix-up of traditional and
modern medications (orthodox) among the respondents in the treatment of
malaria. A good number of he respondents (53.19%) visited the chemist each time
they fell ill of malaria. Some (37.85%) used herbs called ‘OgwuIgbo’.Some of the
herbs were boiled before drinking, inhaled or used to bathe. Only a few of the
respondents(5.98%) visited the hospital. Prevention against mosquito bites
included use of aerosols (17.13%), use of mosquito coils (49.60%), and use of
nchawu (15.74%) among others.
Aribodoret al (2004), reported that the management practices of the Azia
community, IhialaL.G.A.AnambraState include: attend hospitals (24.6%); use
traditional medicine from local healers (12.0%) and buy anti-malarial without
physician prescription (25.0%).
Similarly result from Ibeju-Lekki communities of South Western Nigeria (Nebeet
al, 2002) reported a general low level of knowledge on the management practice
adopted by mother and care providers. The prevailing methods of management of
childhood convulsion were noted: traditional healers (26.4%), health centers
(16.6%), among others.
Furthermore, Obiukwu and Okwuonu (2008) in a study of prevalence of malaria
and management practices adopted in Abba Njikoka L.G.A., Anambra State,
Nigeria reported that greater number of respondents resorted to patent medicine
128 (36.6%) for treatment purposes. None of the poorest respondents used
prophylactic drugs and insecticide treated nets. They attributed this to financial
constriant and non-awareness of these preventive measures by the people.
19
Oyewole and Ibidapo (2007) in a study of attitudes to malaria prevention,
treatment and management strategies associated with the prevalence of malaria in
a Nigerian urban center, reported that preventive measures adopted against
mosquito bite include sleeping under net (treated and untreated) 17(4.2%), door
and
window
screening
37(9.2%),cover
cloth
55(13.8%),
mosquito
repellant/insecticides spray 39(9.8%), environmental hygiene 26(6.5%), herbal
decoction 26(6.5%), and chemoprophylaxis 45(11.3%). Also in the study, self
treatment (medication) accounted for 267(66.8%) as against hospital treatment
93(23.3%).Attapeu provincial Health service (2003) in a survey of knowledge,
attitude and practice (KAP) in Lao PDR reported that 48.5% responded that they
visit a doctor for treatment in hospital, 17.8% said they go to a health center,
51.8% goes to buy and take medicine, by themselves and 9.5% undergoes
traditional healing practice. The preventive strategies adopted include: sleeping
under mosquito nets (91.3%), drinking boiled water (15.5%), keeping the house
and surrounding clean (54.8%) and wearing long sleeves shirts (23%).
Legesseet al(2007) in a survey of KAP about malaria transmission and its
preventive measures among households in urban areas of Assosa zone, western
Ethiopia, reported that the major malaria preventive measures includes: sleeping
under a mosquito net (55%) and eliminating mosquito breeding sites (52%)
respectively.
Abd/El-Gayoumet al (2006) in a survey of knowledge, practices and perceptions
which affect acquiring malaria in man –made malaria area in Khartoum state,
Sudan reported that the preventive measures against malaria were: insecticides use
(22.9%),bed nets (23.9%), screened window (25.8%) and 39.5% reported no
attempt to use any preventive measures. Among the treatment methods adopted
were: health centers (83.2%), private clinics (65.9%) and hospitals (42.5%)
20
Commenting on malaria control, through treatments, Foster (1995) while
investigating on rural malaria in Gambia, reported that a large proportion of
malaria patients in most endemic areas, receive some form of treatment in the
home or community without ever making contact with the formal health services,
and that home treatment of fever in Africa South of the Sahara can account for up
to 75% of all cases. Ezedinachiet al (1997) working on perception of malaria
infection by people in two rural communities (Awi and IkotEdemOdo) in Cross
River State of Nigeria, also reported that unspecified drugs and traditional
medicines were initial treatment responses, while formal health sector was
consulted only if home initiated measures failed. Also Uzochukwuet al (2008)
while investigating Rural-Urban (AmechiAwkunanaw – Uwani) differences in
maternal responses to childhood fever in South East, Nigeria, reported that surveys
in Africa revealed that 80-90% of fever presumed to be malaria cases were treated
at home, while formal health care is sought only if initial treatment fails. Tore
(1995) reported, in WHO 12thProgramme Report, (1995) that in most malaria
treatment, 80% in malaria endemic areas like Nigeria is handled at home without
microsopic confirmation of the suspected malaria episode. Coker and Adesegun
(2006) were also of same opinion by reporting that in Africa almost 70-80% of the
population patronise traditional healers for their medical care, and that in rural
communities, the herbalists or traditional healer is usually the first port of call in
the event of illness. Salakoet al (2001) and Iweze (1987) reported that in Nigeria,
patent medicine stores (PMS) are usually the first choice in health care and a
recognised primary source of orthodox drugs fro both rural and urban populations,
especially the poor.
21
2.4 TRANSMISSION OF MALARIA
On transmission of this disease, Ernest et al (1974) reported that the transmission
of malaria is limited to the tropics and subtropical regions of the world. However,
they remarked that in the past, transmission occurred in many temperate regions
and that in the zone, malaria was unstable and relatively easy to control or
eradicate, while tropical malaria is often more difficult to eradicate. This is very
evident in Nigeria. Markellet al (1999) reported that transmission of all species of
malaria parasites depends on the presence of both the suitable species of
Anopheline mosquitoes and of the (gametocyte-bearing) humans, and that the
suitability of a mosquito as a vector of human malaria disease depends not only on
the physiologic adaptation to the infection, but also on such factors as feeding
preferences, hour of biting and flight, resting and breeding habits. They also
reported that favourable breeding places abound in the tropics, such as old cans,
coconut shells, wells, old tyres, poor drainage systems, bushes and hedges around
dwelling houses etc. These factors, obviously, promote mosquito multiplication.
Apart from transmission through the bites of infected female Anopheles
mosquitoes, transmission through blood transfusion and mechanical transmissions
through shared syringes by drug users are also known. The World Health Report
(2002) remarked that in areas of stable malaria transmission, very young children
and pregnant women are the population group at highest risk for malaria morbidity
and mortality, and that most children experience their first malaria infection during
their first year or two of lives, when they have not yet acquired adequate clinical
immunity – which makes these early years particularly dangerous. Commenting
22
also on transmission, Murphy and Breman (2001) reporting on malaria
transmission in urban sub-Sahara Africa stated that a review of malaria
transmission in sub-Sahara Africa cities shows the strong likelihood of
transmission occurring within these sprawling cities, whatever the size or
characteristics of their bioecologic environment. However, considerable variation
in the level of transmission exists among cities and within different districts in the
same city.
2.5
Life Cycles of Malaria Parasites
Plasmodium undergoes three (3) cycles: two (2) asexual cycles, which occur in
man and the sexual cycle, which occurs in the mosquito vector
Liver stage: Human infections are initiated when sporozoites are injected with the
saliva during the infected female Anopheles mosquito feeding. The sporozoites
enter the circulatory system and within 30-60 minutes will invade a liver cell. The
speed and selectivity of the process have indicated that sporozoite invasion of
heptatocytes involves parasite-encoded surface proteins and host molecule(s).
Despite the body of information that is available on the biology of the sporozoite,
and the hepatic stages of Plasmodium, the exact route of sporozoites to their target
cells is still not entirely clear (MeisansVerhave, 1998; Sinnis and Sim, 1997).
After invading the heptocytes, the parasite undergoes an asexual replication. This
replicative stage is often called exoerythrocytic (or pre-erythrocytic) schizogony.
Schizogony refers to a replicate process in which the parasite (schizonts)
undergoes multiple rounds of nuclear division without cytoplasmic division
followed by a segmentation, to form a progeny. The progeny, called merozoites
are released into the circulatory system following rupture of the host hepatocyte.
In P.vivax and P.ovale, some of the sporozoite do not immediately undergo a
sexual replication, but enter a dormant phase known as the hypnozoite. This
23
hypnozoites can reactivate and undergo schizogony at a later time resulting in a
relapse. Relapse refers to the reactivation of the infection via hypnozoites.
Recrudescence is used to describe the situation in which parasitaemia falls below
detectable levels and then later increases to a patent parasitaemia, as it is found in
Plasmodium falciparum and P.malariae
Blood Stage:
Sometimes called the erythrocytic stage is initiated with the release of
approximately 105 to 106merozoites from the matured and ruptured schizonts in
the liver. This is the product of 5 to 100 successful sporozoites. These merozoites
liberated into the blood circulation invade passing red blood cells immediately.
After entering the erythrocyte the parasite undergoes a trophic period followed by
asexual replication. The young trophozoite is often called a ring form due to its
morphology in Giemsa-stained blood smears. As the parasite increases in size, this
‘ring’ morphology disappears and it is called a trophozoite.
Nuclear division marks the end of the trophozoite stage and the beginning of the
schizont stage. Erythrocyticschizogony consists of 3-5 rounds (depending on
species) of nuclear replication followed by a budding process. Late stage schizonts
in which the individual merozoites become discernable are called segmenters. The
host erythrocyte ruptures and releases the merozoites. These merozoites invade
new erythrocytes and initiate another round of schizogony.
The blood stage parasites within a host usually undergo a synchronous
schizogony. The simultaneous rupture of the infected erythrocytes and the
concomitant release of antigens and waste products accounts for the intermittent
fever paroxysms associated with malaria.
24
Sexual Stage:
As an alternative to schizogony, some of parasites will undergo a sexual cycle and
terminally differentiate into either micro- or macro gametocytes. The factors
involved in the induction of gametogenesis are not known. However, commitment
to the sexual stage occurs during the asexual erythrocytic cycle that immediately
precedes gametocyte formations. Daughter merozoites from thisschizonts will
develop into either all asexual forms or all sexual forms. Gametocytes do not
cause pathology in the human host and will disappear from the circulation if not
taken up by a mosquito.
Gametogenesis is inductive when the gametes (micro and macro) are ingested by a
mosquito. After ingestion by the mosquito, the microgametocyte undergoes three
rounds of nuclear replications. These eight nuclei then become associated with
flagella that emerge from the body of the microgametocyte. This process is readily
observable by light microscopy due to the thrashing flagella and is called exflagellation. The microgametocyte mature into microgametes.
Ex-flagellation occurs spontaneously when infected blood is exposed to air.
Critical factors involved in the induction of this gametogenesis include: decrease
in temperature, a decrease in dissolved CO2 and the subsequent increase in PH to
above 8.0.
The highly mobile microgamete will seek out and fuse with a macrogamete within
12-hours, the resulting zygote develops into an Ookinete. The Ookinete is a motile
invasive stage, which will traverse both the peritrophic matrix and the midgut
epithelium of the mosquito.
Sporogony:
After reaching the extracellular space between the epithelial cells and the basal
lamina, the Ookinete develops into an Oocyst. The Oocysts undergoes an asexual
replication called sporogony, this generally takes 10-28 days depending on species
and temperature. Upon maturation, the Oocyst, ruptures and release the
25
sporozoites which migrate to the salivary gland of the mosquito (Good et al,
2001). Some of these sporozoites will be expelled into the vertebrate host as the
mosquito takes a blood meal, and thus reinitiate the infection in the vertebrate
host.
Malaria can also be transmitted through blood transfusion from infected person or
transplacentaly from pregnant mother to the fetus. However, transmission of this
nature accounts for a negligible percentage.
2.6 Pathogenesis and Pathology of Malaria
Most of the major clinical manifestations of malaria may be attributed to two
general factors: (1) the host inflammatory response, which produces the
characteristic chills and fever as well as other related phenomena and (2) Anemia,
arising from the enormous destruction red blood cells. Severity of the disease is
correlated with the species producing it. Falciparum malaria is most dangerous and
quartan (P. malariae) and ovale (P. ovale) are the least dangerous.
Typical malaria fever attack: Fever is a common, nonspecific reaction of the
body to infection, functioning at least in part to increase the rate of metabolic
reactions important in host defenses. Malaria fever is correlated with the
maturation of merozoites and rupture of the red blood cells that contain them. The
malaria fever is stimulated by the waste products of the parasites, released when
erythrocytes lyses. Release of these malarial toxins (hemozoin) into the circulation
triggers a burst of tumor necrosis factor, or TNF from activated macrophages
(Kwiatkowski, 1995). Introduction of fever is among the effects of overproduction
of TNF, and TNF toxicity can account for most or all of the typical symptoms.
A few days before first paroxysm, the patient may feel malaise, muscle pain,
headache, loss of appetite and slight fever; or the first paroxysm may occur
abruptly, without prior symptoms. A typical attack of benign tertian (P.
falciparum) or quartan (P. malariae) begins with a feeling of intense cold and rise
in temperature up to 104 oF to 106oF. The teeth chatter and the patient shivers. The
26
hot stage begins within one half to one hour later, with intense headache,
temperature rises to maximum, back and joint pains, vomiting and diarrhea. As
copious perspiration signals the end of the hot stage, the temperature drops back to
normal within two to three hours, and the entire paroxysm is over within 8 to 12
hours. The time periods for the stages are usually somewhat shorter in quartan
malaria, and the paroxysms recur every 72 hours. In vivax malaria the periodicity
is often quotidian early in the infection. Because the synchrony in falciparum
malaria is much less marked, the onset is often more gradual, and the hot stage
extended. The fever may be continuous or fluctuating, but the patient does not feel
well between paroxysms, as in vivax and quartan malaria.
Malaria caused by P. falciparum (called subtertian or malignant tertian malaria) is
the most widespread, accounting for up to 80% of all malaria cases world wide
(Markell and Voge,1992). P. facilparumis the most pathogenic of the human
malaria species with untreated infections causing severe disease and death,
particularly in young children, pregnant women and non-immune adults.
The pathogenicity of P. falciparum is mainly due to:

High levels of parasitaemia resulting in the activation of cytokines and the
destruction of many red cells. Up to 30-40% of red cells may become
parasitized.

The cytoadherence of falciparum parasitized red cells causing the cells to
adhere to one another and to the walls of capillaries in the brain, heart, spleen,
lung, intestine and placenta.
Severe falciparum malaria is associated with: cerebral malaria, black water fever,
severe anemia, hypoglycemia, algid malaria and complications in pregnancy.
Cerebral Malaria: The most common complications of malaria, which may
account for 10% falciparum malaria cases admitted to the hospital and 80% of such
deaths (WHO, 1986). Cerebral malaria may be gradual followed by a coma, an
uncontrollable rise in temperature to above 1080F, and convulsions, especially in
27
children. Death may ensue within a matter of hours. Many parasitized cells can be
found in the capillaries of the brain and in the late stages, hemorrhaging from small
blood vessels can occur.
Anemia: Ogun (2006) described anemia as the commonest complication of malaria
and the complexities is due to the destruction of both parasitized and nonparasitized erythrocytes, inability of the body to recycle the iron bound in hemozoin
and an inadequate erythropoietic response of the bone marrow. This can be severe
and occur rapidly, particularly in children. Why such large numbers of nonparasitized red cells are destroyed is still not understood but some evidence has
indicated complement mediated, autoimmune hemolysis. Both the splenic removal
of red cells and the defective bone marrow response may be due in part to TNF
toxicity (Clark, 1987; Mendis and Carter, 1995). Destruction of erythrocytes leads
to an increase in blood bilirubin. When excretion cannot keep up with formation of
bilirubin, jaundice yellows the skin.
Blackwater Fever: This is a rare but acute condition in which there is a rapid and
massive intravascular haemolysis of both parasitized and non parasitized red cells
resulting in haemoglobinaemia, haemoglobinuria, and fall in haemoglobin. It is fatal
due to renal failure. Following a hemolytic attack the parasites are difficult to find
in the blood.
The urine appears dark red to brown-black (hence the name
blackwater fever) due to the presence of free hemoglobin. The urine also contains
protein, hyaline and granular casts, and epithelial debris. Blackwater fever can
occur in non-immune adults with severe falciparum malaria, and also as
complication of quinine treatment.
Hypoglycemia: This is a condition associated with reduced concentration of blood
glucose. It is a common finding particularly in children and in women with
uncomplicated or severe malaria who are pregnant or have recently delivered as
well as in other cases of severe falciparum malaria (WHO, 1986). This condition is
usually associated with quinine treatment. The pancreatic islet cells are stimulated
by quinine to increase insulin secretion, thus lowering blood glucose (Warren,
1987). This may also be to due to excessive TNF (Warren et al, 1986).
28
Algid Malaria: This condition result when the adrenals are involved. There is
sudden fall in body temperature. It may be associated with abdominal pain,
vomiting, and diarrhea. The may be generalized vascular collapse followed by
shock.
2.7
DIAGNOSIS OF MALARIA
Prompt and accurate diagnosis of malaria is the key to effective disease
management. It is thus of concern that poor diagnosis continues to hinder effective
malaria control. This is due to a combination of factors, prevalence of
asymptomatic infection in certain areas, lack of resources and insufficient access
to trained health care providers and health facilities and widespread practice of
self-treatment for clinically suspected malaria. Several approaches to the diagnosis
of malaria can be adopted; each present characteristics such as cost, ease of
performance and accuracy.
Clinical diagnosis is the most widely used approach. It has been the only feasible
one in many situations, particularly in rural areas and at the periphery of the health
care system where laboratory support to clinical diagnosis does not exist. Among
the many clinical signs and symptoms associated with malaria, the most prominent
is fever, which is often accompanied by chills, perspiration, anorexia, headaches,
vomiting and malaise. In addition to these symptoms of uncomplicated malaria,
other manifestation may develop that signal severe malaria, which is almost
always due to P. falciparum. These include drowsiness with prostration, severe
anemia, cerebral malaria, splenomagaly, hepatomegaly and others. Clinical
diagnosis is easy to perform and require no special equipment. However, the
symptoms of malaria are very non-specific and overlap with those of other febrile
illnesses. A diagnosis of malaria based on clinical grounds alone is therefore
unreliable and when possible should be confirmed by laboratory tests.
Conventional light microscopy is the established without for the laboratory
confirmation of malaria. The careful examination of an expert microscopist of a
well prepared and well-stained blood film remains currently the gold standard’ for
29
detecting and identifying malarial parasites. In most cases, the procedure consists
of collecting the smear and examining the smear through a microscope for the
presence of malaria parasites. Microscopy offers such advantages as:
a.
It is informative since parasite species and the circulating stage is
detected.
b.
It is relatively cheap and the technique can be shared with other disease
control program.
c.
It is sensitive and can detect densities as low as 5-10 parasites, per
microlitre of blood by skilled and careful technicians.
d.
It can provide a permanent record (the smears) of the diagnostic
findings.
The principal demerits of microscopy include being time-consuming requiring (at
least 60 minutes), labor-intensive, depend absolutely on good techniques and
delayed results.
The third approach to malaria diagnosis is the rapid diagnosis tests (RTDS). These
tests are based on the detection of antigens derived from malaria parasites in lysed
blood, using immunochromatographic methods. Most frequently they employ a
dipstick bearing monoclonal antibodies directed against the target parasite
antigens. The test can be performed in about 15 minutes. RDTs are simpler to
perform and to interpret(Quintaniaet al 1998).
30
CHAPTER THREE
3.0 Materials and methods
3.1
The Study Area
The study area is Ndiegoro, a semi-urban community in Aba South L.G.A. in
AbiaState southeastern Nigeria. It is located between latitude 8 o and 10oNof
equator and longitude 8o and 10o E of the meridian. The vegetation is typically
rainforest. The mean annual rainfall of about 2250 to 2500mm and mean annual
temperature is 25 to 27oc with high relative humidity. The rainy season is observed
from May to October while the dry season runs through the months of November
to April. The community is made up of four villages namely: Umudike,
Umuokorie, Umuonyinke and Umuzogwu. The occupation of the people includes:
subsistence farming sometimes combined with petty trading. The main crops
farmed include: cassava, vegetables, cocoyam and yams.
3.2The Study Subjects.
The study subjects include inhabitants, who had resided in Ndiegoro community
for one year and above. The sample population includes all those attending local
hospitals.The samples collection was done at Victory Christian hospital, located in
the community. Permission from the medical director was sought upon presenting
to him the motive of the study. Microscopy was also carried out in the laboratory
section of the hospital. Informed consent was obtained from the participants in the
study. For children in the study, the consent of their parents was obtained prior to
finger prick blood collection.
31
Procedure:
Before the collection of the blood, question was put to the patient whether any
anti-malarial drugs have been taken recently (less than past two weeks).Those who
answered in the positive were dropped while blood samples were collected from
those who answered in the negative.
After the patient information has been recorded in the appropriate form, the blood
films are made as follows.
1.
With the patient’s left hand, palm upwards, the forefinger was selected .
Cotton wool lightly soaked in methylated spirit was used to clean the
finger. With a clean cotton wool the finger was dried, using firm strokes
to stimulate blood circulation.
2.
A disposable sterile blood lancet was used to puncture the ball of the
finger. By applying gently pressure to the finger, the first drop of blood
was expressed and wipe it away with dry cotton wool. Care was taken to
ensure that no strands of cotton remain on the finger.
3.
Handling clean slide only by the edges, the blood was collected as
follows:
Gentle pressure was applied to the finger and a single small drop of blood
was collected onto the middle of the slide, this is for the thin film.
Further pressure was applied to express more blood and two or three large
dropswas collected on the slide about 1cm from the drop intended for the thin
film.
The remaining blood was wiped away from the finger with cotton wool.
4.
Thin Film: Using another clean slide as a “spreader”, and with the slide
with the blood drops resting on a flat, firm surface, the small drop of
blood was touched with the spreader and the blood allowed to run along
32
its edge. The spreader was firmly pushed along the slide, away from the
largest drops, keeping the spreader at an angle of 450. I ensured the
spreader is in even contact with the surface of the slide all the time the
blood is being spread.
5.
Thick Film: Always handle slides by the edges, or by a corner, to make
the thick film as follows: using the corner of the spreader, the larger
drops of blood was quickly joined and spread to make an even thick
film. Care was taken to avoid the blood to be excessively stirred. The
blood could be stirred in a circular form with 3-6 movements.
6.
The blood film was then allowed to air-dry with the slides in a
horizontal position in a safe place. Label the dry film with a marker
pencil by writing across the thicker portion of the thin film the patients’
number and date.
STAINING BLOOD FILMS WITH GIEMSA STAIIN
1.
The film was allows to air-dry thoroughly.
2.
The thin film was fixed by gently dabbing with cotton wool dampened
with methanol for 1-2 minutes. Care was taken to ensure that the methanol
does not touch the thick film.
2.
Gently pour the prepared stain (10% Giemsa solution) on the slide in a
staining dish.
3.
Stain for 5-10 minutes.
4.
Gently flush the stain off the slide by adding drops of clean water; do
not tip the stain and then wash, as this will leave a deposit of scum over
the smear.
5.
The slide was placed in the rack, film side downward, to drain and dry,
making sure the film does not touch the slide rack.
33
REPORTING BLOOD FILMS FOR MALARIA PARASITES
Blood films were examined microscopically using the x40 and x100 objectives.
The 7 x eyepiece was used according to WHO (1991) and Payne (1993). The thick
film allow for the detection of the presence Plasmodium. The film was considered
positive if the ring forms trophozoite or any blood stage of erythrocyte schizogony
was detected. The thick film was considered negative if no parasite were seen after
scanning at least 100 fields. The thin films allows for the identification of the
species of plasmodium including staining and morphological features. The
plasmodium species were identified using the key according to Cheesbrough
(1998).
3.4
Qualitative Data Collection
The structured questionnaires were used. The section A of the questionnaire
was for Bio-data such as: age, sex, marital status, educational
qualifications. Questions on the help-seeking behavior pattern of the
population was asked in section B. Questions on the preventive measures
adopted was asked in section C. Questions on the treatment methods such
as: buy anti -malarial drugs from chemist, attend hospitals, use herbs was in
section D.
3.5
Analysis of Results:
The quantitative data were analyzed using: tabulations, percentages, bar
charts and test of statistically significant differences using chi-square (X2).
The statistical package used was the Minitab software.
34
CHAPTER FOUR
4.0 RESULTS
The results showed that 153 patients were positive for malaria parasite out of the
300 sampled. Therefore the prevalence of malaria was found to be 51.0% for the
period between May and August, 2009. The prevalence of malaria with regards to
age groups were found to be statistically significant (p<0.05)(Appendix 1), the
35
age-specific prevalence rate was also found as follows: 74.3% for age (0-5) yrs,
58.3% for (6-15) yrs, 41.7% for (16-25) yrs, 50.0% for (26-35)yrs, 40.0% (36-45)
yrs, 45.0% for (46>) yrs. (Table 1). It was also observed that all the malaria cases
detected were infections of only P. falciparum. No cases of mixed infections were
identified.
More males 88 (58.7%) were found to be infected than females 65 (43.3%) out of
150 randomly selected male and female each from the sampled population. (Table
2).
The sex specific prevalence were found to be statistically significant
(p<0.05)(Appendix 2). The help-seeking behavior of the respondents was
summarized in table 3
On the management practices of malaria, the following preventive measures were
identified by the respondents: Door/window (10.70%), insecticide bed nets
(treated
and
untreated)(9.00%),
cover
cloth
(11.70%),
Mosquito
repellant/insecticidal spray (23.00%), environmental sanitation (16.70%), using
fan (21.70%) and 1.70% did nothing to prevent mosquito bite (Table 4).
The treatment methods of the sampled population was found to include: Buying of
anti-malarial drugs from chemist shops, attending local hospitals, use of traditional
medicine (herbs), while few have no management at all. Of the 300 patients
sampled, 79 (27.6%) buy anti-malarial drugs from chemist without prescription,
34 (12.0%) attend hospitals while 60 (21.1%) use traditional medicine (herbs) in
their treatment of malaria. It was also found that some individuals use more than
one method in the treatment of malaria. 24 (8.3%) combined the use of traditional
medicine and attend hospitals, 41 (14.4%) combined the use of anti malarial and
traditional medicine and 21 (7.4%) combined the use of anti-malarial and attend
hospital. It was also observed that the practice of using more than one method was
36
by trial and error means and not that they are used concurrently. 12 (4.2%) of the
respondents did nothing about treatment of malaria (table 4)
Results on the influence of educational background in the malaria management of
the people are summarized in Table 5. Of the 300 individuals sampled, 106
(37.2%) had informal education, 63(22.1%) had primary education, 73(25.6%) had
secondary education and 43(15.1%) had tertiary education. It was observed that
the highest percentage of those who attend hospitals to treat malaria had secondary
and tertiary education while the highest percentage of those who buy anti-malarial
drugs over the counter and as well use traditional medicine form healers had
informal or primary education.
37
Table 1:Age Prevalence of malaria infections in the community
Age groups (yrs)
No. Examined
No. Infected %
0-5
35
26
74.3
6-15
72
42 58.3
16-25
72
30
26-35
56
28
50.0
36-45
45
18
40.0
46> 20
8
TOTAL
Df=8,
41.7
45.0
300
p=0.032, p<0.05
153
51.0
Table 2: Sex-prevalence of malaria infection in the community
SEX
NE
Male
150
88 (58.7)
Female
150
65 (43.3)
Total
300
153 (51.0)
Df=1,
NI (%)
p=0.008, p<0.05
Table 3:Help-Seeking Behaviourof Respondent
Age
group (yrs)
Lab Diagnosed
yes (%)
Lab Diagnosed
Occasionally (%)
Lab Diagnosed
No (%)
Total
0-15
59
33
15
107
16 >
34
117
27
178
38
Total
93(32.6)
150(52.6)
42(14.7)
285
Table 4: Preventive Measures Adopted
Agegroup Doors +
window
bed nets
Screen (%)
(%)
0-15
18
16 >14
Untreated ITNS Cover Mosquito EnvtalUsing Insecticide Chemopro- None
(%)
cloth repellant Sanitation fan spray
phylaxis
(%)(%)
15
4
7
Total 32(10.70)
1
22(7.30)
(%)
25
10
5(1.70)
(%)(%)(%)
9
21
31
35(11.7)
Total
29
40(13.30)
20
45
50(16.7)
10
19
65(21.7)
6
1
11
29(9.7)
4
1 7(5.7)
129
171
5(1.7)
300
Table 5: Methods of malaria treatment adopted
Age
Buy
Group antimalarial
(yrs)
from Chemist
(%)
Attend
hospital
(%)
0-15
32
23
12
8
12
16>
47
11
48
16
29
60(21.1)
24(8.3)
41(44)
Total 79(27.6)
34(12.0)
Use traditional
medicine (%)
Trad. Med.
+
Attend hosp.
Antimalarial +
Trad. Med.
(%)
Antimalarial +
Attend (%)
Hosp.
Antimalarial None
trad. Med.
(%)
Total
14
5
2
107
7
9
10
178
12(4.2)
285
21(7.4)
14(5.0)
Table 6: Educational background and the method of treatment of the people
Treatment method
Respondents
Informal Primary Secondary
Tertiary
Buy antimalarial
from Chemist
79
34
16
30
9
Attend hospital
34
5
7
9
13
Use traditional Medicine
60
35
13
8
4
14
8
4
2
0
Traditional medicine
and Attend Hospital
Antimalarial and
Traditional medicine
Antimalarial, Hospital
41
20
11
7
3
39
and traditional medicine
21
10
None
120
2
Total
285
106
5
6
63
4
2
4
73
43
CHAPTER FIVE
Discussion:
Malaria is acknowledged to be by far the most important tropical parasitic disease
causing great suffering and loss of lives (WHO, 1993).The days of labor lost, the
cost of treatment of patients and the negative impact of the disease make malaria a
major social economic burden (WHO, 1993).
Results from the study indicate that more than half (51.0%) of the individuals
examined were positive for malaria parasites in their blood.Table 1 shows the
prevalence of malaria infection with regards to age groups with the age group (05) years recording highest prevalence (74.3%). The trend of this result agrees with
Salako, (1994) and Steketee, (2001). Steketee, (2001) reported that in areas of
stable malaria transmission, very young children are the population group at
highest risk for malaria morbidity and mortality, and that most children experience
their first malaria attack during their first or two of life, when they have not yet
acquired adequate clinical immunity. He also reported that 90% of all deaths from
malaria occur in Africa in young children.
40
High prevalence rate in the age group (0-5) could be due to low transferred
maternal immunity or inadequate protection. Also the age group (6-15) and (1625) which constituted 58.30% and 41.70% of the population studied belong to the
school aged class. This, therefore, may suggest that malaria is a major cause of
school absenteeism among the population during the period the study was
undertaken. According to WHO (1996), Malaria has been found to be one of the
most common cause of school absenteeism, affecting over one –third of primary
school children during a school term with more than half of the students having
up to two attacks, typically missing a week more of school with each attack.
Interestingly only the ring form stage of Plasmodium falciparum represents a
major public health problem in Nigeria. In related studies carried out in Awka
South East Nigeria (Mbanugo and Ejims, 2000), and in LagosState, South West
Nigeria (Asianyaet al, 1999), and in Azia, AnambraState (Aribodoret al, 2003)
only infections of P. falciparum were reported. These findings contrast with other
studies (Ukpai and Ajoku, 2001; Matur et al 2001) were cases of P.faliciparumand
P. malariaeor mixed infections with P. falciparum and P. malariaewere reported.
It is however, pertinent to state that malaria caused by P. falciparum is the most
widespread, accounting for up to 80% of malaria in Africa (WHR, 2002, Markell
and Voge,1992).
Sex-wise, more males were infected (58.7%) than females (43.3%) (table 2). This
could be due to the fact that the male expose themselves more than females
especially when the weather is hot, by removing their shirts and going bare
bodied. By doing this, they expose themselves to more mosquito bites.
On help-seeking behavior by the participants when sick, table 3 shows that more
persons 150 (52.6%) indicated going to medical laboratory occasionally for the
diagnosis of their ill health. 42 (14.7%) respondents indicated not going to
41
laboratory. Oral interviews on some of the participant that indicated not going to
laboratories revealed that this trend is either due to poverty, uncertainty of test,
time consuming process and poor knowledge on the right steps to take when sick.
Table 4 shows the preventive measures against mosquito bites by the participants.
A greater number of the respondents indicated use of fan (21.70%) and
environmental sanitation (16.70%). The use of insecticide treated bed nets (ITNs)
was indicated by the least group o f the respondents 5(1.7%). The reason for this
low patronage was not be unconnected with the level of awareness, availability
and affordability(Macintyre et al.,2002; Olayemiet al., 2003). Also 5(1.7%) of the
respondents indicated that they did nothing as regards prevention of malaria
infection. This agrees with the findings of Onwujekwuet al (2005) and Zambia
RBM report (2001).Onwujekwuet al (2005) after investigating on the use of ITNs
in Achi, Oji river L.G.A, Enugu State, reported of a very low use of the net by the
people, while Zambia RBM report (2001), stated that poor families live in
dwellings that offer little protection against mosquitoes and are less able to pay
either for effective malaria treatment or for transportation to a health facility.
On methods of malaria treatment by the participants, table 5 revealed that a greater
number (27.6%) of respondents buy anti-malarial drugs from chemist without
prescription by a physician, 34 (12.0%) of the respondents consult the physician
by attending hospitals, while 60 (21.1%) of the respondents depend solely a
traditional medicine from traditional healers. These findings agree with the
observations of Ezedinachiet al (1997) and Foster (1995).
Ezedinachiet al (1997) working on perception of malaria infection by people in
two rural communities (Awi and IkotEdemOdo) in Cross River state of Nigeria,
reported that traditional medicines were initial treatment responses, while formal
health sector was consulted only if home initiated measures failed. Foster (1995)
42
investigating on rural malaria in Gambia, reported that a large proportion of
malaria patients receive some form of treatment in the home or community
without ever making contact with the formal health services.
Of special interest is the revelation that few individuals (4.2%) indicated doing
nothing at all to manage malaria. Whether they do not suffer the effects of the
disease was not investigated. But it has been proved that some inherited disorders
of haemoglobin such as sickle cell confer a reasonable degree of resistance against
malaria to certain groups of individuals and that those individuals who are
heterozygous for haemoglobin (AS) suffer malaria less frequently and less
severely than normal individuals (Olumeseet al, 1997).
An attempt was made to relate the management practices of the people with
educational qualification possessed by individuals. It was interesting to observe
the highest percentage of those who attend hospitals to treat malaria were those
processing secondary (26.5%) and tertiary education (38.2%). On the other hand,
the highest percentage of those who buy anti-malarial drugs over the counter and
those who use traditional medicine possessed informal and primary education.
Again, the highest percentages of those who make use of traditional medicine
were those possessing informal (57.1%) and primary education (21.7%). It was
also observes that the lowest percentage of those who attend hospitals, possessed
informal education (14.7%) (Table 6). From the foregoing, it is possible to
conclude that the higher the education level of an individual, the better the
malariamanagement practices. The level of education an individual possess
directly improves the awareness of the individual to disease conditions.In this era
of roll back malaria, this particular observation has emphasized the need for the
people to be more aware of the disease through functional education and public
enlightenment program.Health education therefore becomes very important to
teach people the simple relationship between mosquito bites and malaria, the need
43
to keep their environment clean and tidy, destroying anything that may become a
conducive breeding site for malaria vectors and the current trends in the effective
management of malarias. For a holistic control of malaria, therefore, everybody,
that is, individuals, private agencies and government should be involved.
CHAPTER 6
SUMMARY AND RECOMMENDATION
6.1
Summary
This research set out to determine the prevalence of malaria infection among
members of Ndiegoro community, Aba South L.G.A., AbiaState, attending
hospital and to ascertain their management practices.
The prevalence of malaria parasites was done using both thick and thin
blood film microscopy on those attending local hospitals. On the knowledge
of management practices of the people, qualitative data was elicited using
structured questionnaire. It was also part of the objectives of the research to
determine association (if any) of the level of education and method of
treatment of malaria adopted. Similarly, age-specific and sex-specific
prevalence were observed.
The overall prevalence of malaria was found to be 51%. All the cases of
malaria diagnosed were infection of Plasmodium falciparum. It was found
that the preventive measures against mosquitoes bites adopted by the
44
community includes: door and windows screen, untreated bed nets, ITNs,
mosquitoes repellent, environmental sanitation, using fan, insecticide spray,
and chemo-prophylaxis. Also the malaria treatment methods by the people
of the community include: the use of traditional medicine, the buying of
anti-malarial from chemist without prescription of a physician, and
attendance of local hospitals. Some people combine various management
practices out of ignorance and poverty. Based on these findings and
observations, the following recommendations are for the study community
and for the general purpose of making significant difference in the bid to
contain malaria in endemic areas.
6.2
Recommendation for Ndiegoro Community
1.
A good percentage of the people buy anti-malarial drugs from shops
to treat malaria. The World Health Organization (1999) in one if its
studies observed that the management of malaria in the homes could
be markedly improved by the use of genuine blister package doses of
anti-malarial. The same study revealed that prepackaging of antimalarial ensures compliance with full course of treatment and drug
management resulting in reduced cost of treating malaria and reduced
waiting times in the drug dispensaries. Unfortunately fake drugs in
shops markets are limiting this important malaria control practice. It
therefore becomes necessary that government at all levels, market
unions and pharmaceutical societies should work closely and win the
war against fake drugs for the special benefit of the health of the poor.
2.
There is need to educate the community on the appropriate practices
in the management of malaria. This is necessary since a good number
of the people are either uneducated or poorly educated. Therefore,
45
adequate sensitization through electronic media, seminars and
workshops in advocated.
6.3
Recommendation for reducing malaria burden
For effective control of malaria including prevention and treatment,
the government at all levels should muster the political will to
implement the existing tools towards the eradication of malaria. To
achieve this, the following recommendations are made:
1.
Related studies to this research work should be sponsored within
regions with special interest in rural communities. These will
reveal the patterns of the diseases within an area and enable use of
the most effective control measure, thus improving the health of
the people.
2.
It has become increasingly appreciated that multi-sectorial
approach to disease control is a better approach than monosectorial. It therefore becomes imperative that various sectors of
the government should be adequately educated to understand the
roles each can play in disease control. For instance. Ministries of
Agricultures, Natural Resources, Housing and Environment and
others should be made to closely interact with the ministry of
Health so as to appreciate the impact their involvement can make
in health of the people. Such roles by other ministry should center
on poverty eradication.
3.
Since ignorance is still an obstacle against the control of malaria, it
is important to recommend that adequate airtime is given to
malaria control programs in the electronic media, so that people
especially the rural dwellers will know how to prevent and manage
the disease.
46
4.
Since malaria is endemic in Nigeria and constitutes a greater
percentage of outpatients consultation in hospitals, it is
recommended that free medical services should be provided for
malaria patients. This will definitely make the difference in
reducing the burden of the disease among the citizenry.
5.
Since Plasmodium falciparum was the only Plasmodium parasite
found prevanlent in the study, it is safe to recommend the use of
easy-to-perform rapid immunodiagnostic techniques in the
diagnosis of malaria. The usage is recommended because results
obtained from such diagnosis could be quite reliable in the
treatment of the infection.
6.
In this era of “Roll Back Malaria” whose approach appears to be
mainly preventive, using insecticide treated bed nets (ITNs) to
limit both the mosquito population and man-mosquito contact, it is
necessary it emphasize the need to make chemoprophylaxis and
chemotherapy as important as the use of ITNs. This has become
imperative since the long-term effects of the mosquito vector and
man is yet to be fully known. It is therefore recommended that
equal emphasis be paid to both the development and use of ITNs
and anti-malarial drugs.
In conclusion, an integrated approach which combines attacking both the
parasite and vectors of the diseases with proper environmental management
as well as positioning man to his roles in diseases control will definitely lead
to a reduced burden of malaria and increase economic development of the
people.
47
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QUESTIONNAIRE
NNAMDIAZIKIWEUNIVERSITY
AWKA
DEPARTMENT OF PARASITOLOGY AND ENTOMOLOGY
TOPIC:
The prevalence of malaria infection among members of
Ndiegoro community, Aba South L.G.A., AbiaState, attending
hospital and to ascertain their management practices.
61
Dear Respondents,
The above study is being carried out by me, of the above
department, NnamdiAzikiweUniversity, Awka. Kindly assist me by
ticking (√) appropriately in the columns provided. Please be very
honest in your response to each item. Your co-operation is highly
appreciated. All information will be treated in confidence.
SECTION A: PERSONAL DATA
1.
Sex: Male [ ]
2.
Age (Please specify) [ ]
3.
Educational Qualification:
4.
Female [ ]
a.
Informal [ ]
b.
Primary [ ]
c.
Secondary [ ]
d.
Tertiary [ ]
Marital Status: Single [ ] Married [ ]
SECTION B.
5.
How often is malaria diagnosed?
a.
very often [ ]
b.
occasionally [ ]
c.
none at all [ ]
SECTION C
6. How do you mosquitoes bite prevent?
a.
door and window screen [ ]
b.
untreated bed nets
c.
Insecticide treated nets(ITNs) [ ]
[ ]
62
f.
d.
cover cloth [ ]
e.
mosquito repellant [ ]
environmentalsanitation [ ]
g.
using fan [ ]
h.
insecticide spray [ ]
i.
chemoprophylaxis [ ]
j. none [ ]
SECTION D
7.
How do treat malaria you?
a. buy antimalarial drugs from chemists [ ]
b. attend hospitals [ ]
c. use traditional medicine(herbs) [ ]
d. trad.med and attend hospital [ ]
e. antimalarial drugs and trad. Med [ ]
f. antimalarial drugs and attend hospital [ ]
g. antimalarial drugs &trad. Med.& attend hospital [ ]
h. none [ ]
APPENDIX
MINITAB OUTPUT
Chi-Square Test (Dependence of prevalence on age)
Expected counts are printed below observed counts
0-5
No infec No uninf
Total
26
9
35
17.73
17.27
6-10
25
20.27
15
19.73
40
11-15
17
16.21
15
15.79
32
16-20
14
24
38
63
19.25
18.75
21-25
16
17.23
18
16.77
34
26-30
10
11.65
13
11.35
23
31-35
18
16.72
15
16.28
33
36-40
11
14.19
17
13.81
28
41>
15
18.75
22
18.25
37
Total
152
148
300
Chi-Sq=
3.854 + 3.958 +
1.105 + 1.135 +
0.038 + 0.039 +
1.433 + 1.472 +
0.087 + 0.090 +
0.235 + 0.241 +
0.098 + 0.101 +
0.716 + 0.735 +
0.749 + 0.769 =
DF = 8, P-Value = 0.032
16.855
Interpretation: Since the p-value(0.032) is less than 0.05(level of
significance) we reject the hypothesis that prevalence of..... does not depend
on age.
APPENDIX 2
Chi-Square Test(Dependence of prevalence on sex)
Expected counts are printed below observed counts
No_infecNo_uninf
Total
Male
88
62
76.50
73.50
Female
Total
150
65
76.50
85
73.50
150
153
147
300
Chi-Sq=
1.729 + 1.799 +
1.729 + 1.799 =
DF = 1, P-Value = 0.008
7.056
Interpretation: since the p-value is less than 0.05, we reject Ho and conclude that prevalence
64
depends on sex.