Shifting from presumptive to test-based management of malaria - technical basis and implications for malaria control in Ghana

Malaria treatment health seeking behaviors among international students at the University of Ghana Legon

INTRODUCTION

Appropriate management of malaria demands early health seeking behaviour upon suspicion of malaria-like symptoms. This study examined malaria treatment seeking behaviour and associated factors among international students at University of Ghana.

METHODS

The study used a cross-sectional and quantitative approach. Data collection was undertaken using a structured questionnaire administered on a random sample of 264 international students. Data obtained on malaria treatment and factors influencing treatment behaviors were analyzed using IBM, SPSS Statistics version 22. Associations between individual characteristics and Malaria treatment seeking behavior was assessed by Pearson Chi-square(X2) test of independence. Binary logistic regression model was built using a backwards Wald approach, with variables retained at Wald p-value <0.05.

RESULTS

The findings show that 35% of the respondents obtained self-prescribed antimalarial at their utmost first choice of Malaria treatment. At bivariate level, a significant relationship between Malaria health-care seeking behaviour and:- Respondents continent, X2(1, N = 264) = 7.936, p = .005; Service accessibility, X2(1, N = 264) = 7.624, p = .006; Wait time, X2(1, N = 264) = 22.514, p <0.001; Treatment cost, X2(1, N = 264) = 97.160, p <0.001; Health insurance, X2(1, N = 264) = 5.837, p = 0.016, and Perceived staff attitude, X2(1, N = 264) = 18.557, p < 0.001. At multivariable analysis, inappropriate malaria health seeking behaviours was associated with low perceived service accessibility as (≥30mins) (aOR = 6.67; p<0.001), perceived long wait time (≥30mins), (aOR = 5.94; p = 0.015), perceived treatment cost affordability (<15 GHC) (aOR = 19.88; p<0.001) and age group: -34-41years (aOR = 8.83; p<0.001).

CONCLUSION

There were widespread inappropriate health-care seeking behavior for Malaria treatment among international students. Improving accessibility to malaria treatment services, reducing wait time at health facilities and the treatment cost will address inappropriate malaria treatment health seeking behaviours among the international students.

The Problem of Antimalarial-Drug Abuse by the Inhabitants of Ghana

Introduction: Malaria is still a huge social and economic health problem in the world. It especially affects the developing countries of Africa. A particular problem is the misuse and abuse of over-the-counter antimalarials. This problem could lead to the emergence of drug-resistant strains and the subsequent elimination of more antimalarials from the list of effective antimalarials in Ghana. Methods: During the implementation of the study, an original questionnaire was used to collect data among Ghanaians on their knowledge of malaria, attitude towards antimalarials and their use of antimalarials. Results: The proportion in the analyzed subgroups was compared using the chi-square test. The analysis was conducted using TIBCO Software Inc., Krakow, Poland (2017) and Statistica (data analysis software system), version 13. In total, 86.29% of respondents knew the symptoms of malaria (p = 0.02) and 57.2% knew the cause of malaria (p < 0.001). Respondents with higher education were significantly more likely to know the symptoms of malaria (96%) p < 0.001. In the study group, only 74.59% of the respondents consulted medical personnel before taking the antimalarial drug (p = 0.51) and only 14.2% of the remaining respondents performed a rapid diagnostic test for malaria. Conclusions: The awareness of Accra and Yendi native inhabitants about the causes and symptoms of malaria and alternative ways of prevention is quite high. People's education very significantly influences the way Accra residents deal with suspected malaria. Widespread public education and awareness and accessibility to places where antimalarial drugs are sold play a very important role in the proper use of antimalarial drugs.

Assessment of the performance and challenges in the implementation of the test, treat and track (T3) strategy for malaria control among children under-five years in Ghana

BACKGROUND

The World Health Organization recommended the Test, Treat and Track (T3) strategy for malaria control that, every suspected malaria case should be tested prior to treatment with Artemisinin-based combination therapy (ACT) and tracked. We assessed the performance and challenges in the implementation of T3 strategy among children under-five years in Volta and Oti Regions of Ghana.

METHOD

A descriptive cross-sectional study was carried in 69 health facilities. Exit interviews were conducted for caregivers of children with fever using a semi-structured questionnaire. Clinicians were interviewed at the out-patient department in each facility. Descriptive statistics was conducted, Chi-square test and logistic regression were used to determine the associations between completion of T3 and independent variables.

RESULTS

Most children, 818/900 (90.9%) were tested for malaria and 600/818 (73.4%) were positive for malaria parasitaemia using rapid diagnostic test. Of those testing positive for malaria, 530/600 (88.3%) received treatment with ACTs. Half, (109/218) of the children testing negative for malaria also received ACTs. Also, 67/82 (81.7%) of children not tested for malaria received ACTs. Only 408/900 (45.3%) children completed T3 with Community Health-based Planning Services (CHPS) compound having the highest completion rate 202/314 (64.3%). CHPS Compounds were 6.55 times more likely to complete T3 compared to the hospitals [(95% CI: 3.77, 11.35), p<0.001]. Health facilities with laboratory services were 2.08 times more likely to complete T3 [(95% CI: 1.55, 2.79), p<0.001] The main challenge identified was clinicians' perception that RDTs do not give accurate results.

CONCLUSION

Testing fever cases for malaria before treatment and treating positive cases with ACTs was high. Treating negative cases and those not tested with ACTs was also high. Health facilities having laboratory services and facility being CHPS compounds were key predictors of completing T3. Clinician's not trusting RDT results can affect the T3 strategy in malaria control. Periodic training/monitoring is required to sustain adherence to the strategy.

Trends in health workers' compliance with outpatient malaria case-management guidelines across malaria epidemiological zones in Kenya, 2010-2016

BACKGROUND

Health workers' compliance with outpatient malaria case-management guidelines has been improving, specifically regarding the universal testing of suspected cases and the use of artemisinin-based combination therapy (ACT) only for positive results (i.e., 'test and treat'). Whether the improvements in compliance with 'test and treat' guidelines are consistent across different malaria endemicity areas has not been examined.

METHODS

Data from 11 national, cross-sectional, outpatient malaria case-management surveys undertaken in Kenya from 2010 to 2016 were analysed. Four primary indicators (i.e., 'test and treat') and eight secondary indicators of artemether-lumefantrine (AL) dosing, dispensing, and counselling were measured. Mixed logistic regression models were used to analyse the annual trends in compliance with the indicators across the different malaria endemicity areas (i.e., from highest to lowest risk being lake endemic, coast endemic, highland epidemic, semi-arid seasonal transmission, and low risk).

RESULTS

Compliance with all four 'test and treat' indicators significantly increased in the area with the highest malaria risk (i.e., lake endemic) as follows: testing of febrile patients (OR = 1.71 annually; 95% CI = 1.51-1.93), AL treatment for test-positive patients (OR = 1.56; 95% CI = 1.26-1.92), no anti-malarial for test-negative patients (OR = 2.04; 95% CI = 1.65-2.54), and composite 'test and treat' compliance (OR = 1.80; 95% CI = 1.61-2.01). In the low risk areas, only compliance with test-negative results significantly increased (OR = 2.27; 95% CI = 1.61-3.19) while testing of febrile patients showed declining trends (OR = 0.89; 95% CI = 0.79-1.01). Administration of the first AL dose at the facility significantly increased in the areas of lake endemic (OR = 2.33; 95% CI = 1.76-3.10), coast endemic (OR = 5.02; 95% CI = 2.77-9.09) and semi-arid seasonal transmission (OR = 1.44; 95% CI = 1.02-2.04). In areas of the lowest risk of transmission and highland epidemic zone, none of the AL dosing, dispensing, and counselling tasks significantly changed over time.

CONCLUSIONS

There is variability in health workers' compliance with outpatient malaria case-management guidelines across different malaria-risk areas in Kenya. Major improvements in areas of the highest risk have not been seen in low-risk areas. Interventions to improve practices should be targeted geographically.

Evaluating interventions to improve test, treat, and track (T3) malaria strategy among over-the-counter medicine sellers (OTCMS) in some rural communities of Fanteakwa North district, Ghana: study protocol for a cluster randomized controlled trial

Background

The World Health Organization initiated test, treat, and track (T3) malaria strategy to support malaria-endemic countries in their efforts to achieve universal coverage with diagnostic testing, antimalarial treatment, and strengthening surveillance systems. Unfortunately, T3 is not adopted by over-the-counter medicine sellers (OTCMS) where many patients with malaria-like symptoms first seek treatment. Sub-Saharan African countries are considering introducing and scaling up RDTs in these outlets to reduce malaria burden. In this context, this study is aimed at improving implementation of the T3 among OTCMS using a number of intervention tools that could be scaled-up easily at the national level.

Methods/design

The interventions will be evaluated using a two-arm, cluster randomized trial across 8 rural communities (4 clusters per arm), in two adjacent districts (Fanteakwa North and Fanteakwa South districts) of Ghana. A total of 8 OTCMS in the intervention arm and 5 OTCMS in the control arm in the selected communities will participate in the study. In the intervention arm only, subsidized malaria rapid diagnostic test (mRDT) kits will be introduced after the OTCMS have been trained on how to use the kit appropriately. Supervision, technical assistance, feedbacks, and collection of data will be provided on a regular basis at the participating medicine stores. The primary outcome is the proportion of children under 10 years with fever or suspected to have malaria visiting OTCMS and tested (using mRDT) before treatment. Secondary outcomes will include adherence to national malaria treatment guidelines and recommended mRDT retail price. Outcomes will be measured using mainly a household survey supplemented by mystery client survey and a surveillance register on malaria tests conducted by the OTCMS during patient consultations. Data collected will be double entered and verified using Microsoft Access 2010 (Microsoft Inc., Redmond, Washington) and analyzed using STATA version 11.0.

Discussion

The trial will provide evidence on the combined effectiveness of provider and community interventions in improving adherence to the T3 initiative among OTCMS in rural Ghana.

Ethical clearance

NMIMR-IRB CPN 086/18-19

Trial registration

ISRCTN registry ISRCTN77836926. Registered on 4 November 2019.

The Accuracy and Perception of Test-Based Management of Malaria at Private Licensed Chemical Shops in the Middle Belt of Ghana

The sale of artemisinin-based combination therapy (ACT) by private licensed chemical shops (LCS) without testing is contrary to current policy recommendations. This study assessed the accuracy and perception of test-based management of malaria using malaria rapid diagnostic test (mRDT) kits at private LCS in two predominantly rural areas in the middle part of Ghana. Clients presenting at LCS with fever or other signs and symptoms suspected to be malaria in the absence of signs of severe malaria were tested with mRDT by trained attendants and treated based on the national malaria treatment guidelines. Using structured questionnaires, exit interviews were conducted within 48 hours and a follow-up interview on day 7 (±3 days). Focus group discussions and in-depth interviews were also conducted to assess stakeholders' perception on the use of mRDT at LCS. About 79.0% (N = 1,797) of clients reported with a fever. Sixty-six percent (947/1,426) of febrile clients had a positive mRDT result. Eighty-six percent (815/947) of clients with uncomplicated malaria were treated with the recommended ACT. About 97.8% (790/808) of clients with uncomplicated malaria treated with ACT were reported to be well by day 7. However, referral for those with negative mRDT results was very low (4.1%, 27/662). A high proportion of clients with a positive mRDT result received the recommended malaria treatment. Test-based management of malaria by LCS attendants was found to be feasible and acceptable by the community members and other stakeholders. Successful implementation will however require effective referral, supervision and quality control systems.

Knowledge, attitudes and practices regarding malaria in people living with HIV in rural and urban Ghana

BACKGROUND

One of the malaria vulnerable groups is people living with HIV. This study investigated knowledge, attitude and practices (KAP) towards malaria in people living with HIV attending anti-retroviral therapy (ART) clinics in rural and urban Ghana.

METHODS

In this descriptive cross-sectional study patients attending the ART clinics in Atibie (rural area) and Accra (urban area) were interviewed on their knowledge, attitude and practices regarding malaria. Finger-prick capillary blood was tested for Plasmodium spp. with rapid diagnostic tests. Multivariate regression analysis was used to determine the influence of KAP on malaria prevalence.

RESULTS

Parasitemia was generally more frequent among HIV positive individuals in the rural area (29/116; 25%) in the rural area than in the urban area (35/350; 10%). Inaccurate knowledge of cause of malaria and prevention methods were associated with increased odds of malaria parasitemia; [OR = 1.51 (CI: 1.29-5.12); p < .05] and [OR = 2.59 (CI: 2.53-4.75); p < .05], respectively. There were disparities in socio-economic factors. For instance, low level of education was higher in the rural area (45/116; 38.8%) compared to the urban area (121/350; 34.6%).

CONCLUSIONS

Malaria control efforts may yield further results when the knowledge and socio-economic gap between rural and urban areas is closed.

Plasmodium falciparum diagnostic tools in HIV-positive under-5-year-olds in two ART clinics in Ghana: are there missed infections?

Background

Plasmodium falciparum, the most dominant species in sub-Saharan Africa, causes the most severe clinical malaria manifestations. In resource-limited Ghana, where malaria and HIV geographically overlap, histidine-rich protein 2 (HRP2)-based rapid diagnostic test (RDT) is a faster, easier and cheaper alternative to clinical gold standard light microscopy. However, mutations in parasite hrp2 gene may result in missed infections, which have severe implications for malaria control.

Methods

The performance of a common HRP2-based RDT and expert light microscopy in HIV-positive and HIV-negative children under 5 years old was compared with PCR as laboratory gold standard. Finger-prick capillary blood was tested with First Response^® Malaria Ag P. falciparum (HRP2). Giemsa-stained thick and thin blood films were examined with ≥ 200 high power fields and parasites counted per 200 white blood cells. Nested PCR species identification of P. falciparum was performed and resolved on agarose gel. False negatives from RDT were further tested for deleted pfhrp2/3 and flanking genes, using PCR. The study was performed in two anti-retroviral therapy clinics in Accra and Atibie.

Results

Out of 401 participants enrolled, 150 were HIV positive and 251 HIV negative. Malaria was more prevalent in children without HIV. Microscopy had a higher sensitivity [100% (99–100)] than RDT [83% (53.5–100)]. Parasites with pfhrp2/3 deletions contributed to missed infections from RDT false negatives.

Conclusion

Circulation of malaria parasites with pfrhp2/3 deletions in this population played a role in missed infections with RDT. This ought to be addressed if further strides in malaria control are to be made.

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2231-7) contains supplementary material, which is available to authorized users.

Prevalence of Plasmodium falciparum and non-P. falciparum infections in a highland district in Ghana, and the influence of HIV and sickle cell disease

BACKGROUND

In the past two decades, there has been a reported decline in malaria in Ghana and the rest of the world; yet it remains the number one cause of mortality and morbidity. Human immuno-deficiency virus (HIV) and sickle cell disease (SCD) share a common geographical space with malaria in sub-Saharan Africa and an interaction between these three conditions has been suggested. This study determined the Plasmodium falciparum and non-P. falciparum status of symptomatic and non-symptomatic residents of Mpraeso in the highlands of Kwahu-South district of Ghana based on evidence of current national decline. The influence of HIV and SCD on malaria was also determined.

METHODS

Participants were 354 symptomatic patients visiting the Kwahu Government Hospital and 360 asymptomatic residents of the district capital. This cross-sectional study was conducted during the minor rainy season (October-December 2014). Rapid diagnostic tests (RDT), blood film microscopy and real-time polymerase chain reaction assessment of blood were done. Participants who tested positive with RDT were treated with artemisinin-based combination therapy; and assessment of venous blood was repeated 7 days after treatment. HIV screening and haemoglobin genotyping was done. Univariate and multivariate regression analysis was used to determine the influence of SCD and HIV.

RESULTS

Plasmodium falciparum was prevalent at 124/142 (87.3%). Plasmodium malariae was the only non-falciparum species detected at 18/142 (12.7%). HIV and SCD did not significantly increase odds of malaria infection. However, the use of ITN and recent anti-malarial intake significantly decreased the odds of being malaria infected by 0.45-fold and 0.46-fold respectively.

CONCLUSION

Plasmodium falciparum and P. malariae infection are the prevailing species in the study area; albeit varying from the national average. HIV and SCD were not associated with the risk of having malaria.

Cost benefit analysis of malaria rapid diagnostic test: the perspective of Nigerian community pharmacists

Background

In 2010, the World Health Organization issued a guideline that calls for a shift from presumptive to test-based treatment. However, test-based treatment is still unpopular in community pharmacies. This could be due to unwillingness of customers to spend extra finance on rapid diagnostic test (RDT). It could also result from lack of interest from community pharmacists since they may perceive no financial gain attached to this service. This study assessed the cost-benefit of test-based malaria treatment to community pharmacists.

Methods

The study was a community pharmacy-based cross sectional survey. Potential benefit of RDT was determined using customers’ willingness-to-pay (WTP) for service. Average WTP was estimated using contingent valuation. Binary logistic regression was used to assess correlates of WTP acceptance while multiple linear regression was used to model the relationship between the independent variables and WTP amount. Cost associated with provision of RDT was estimated from provider’s perspective. Probabilistic sensitivity analysis was used to capture parameter uncertainty. Benefit-cost ratio (BCR) was calculated to determine study objective.

Results

A total of 135 out of 235 participants (57.4%) responded to the WTP question. Of this subset, 111 participants (82.2%) preferred RDT before malaria treatment. Average WTP [minimum–maximum] was US$1.23 [US$0.0–US$5.03]. Educated participants had 1.8 times higher odds of WTP for RDT. Participants that understood RDT as described in the questionnaire had 18.3 times higher odds of WTP for RDT compared to participants that did not understand RDT as described in the questionnaire. Additionally, a unit increase in level of education (e.g. from primary to secondary school) led to US$0.298 increase in WTP amount for RDT. Also, a unit increase in malaria frequency (e.g. from ‘never’ to ‘rarely’) led to US$0.293 decrease in WTP amount for RDT. Average cost [minimum–maximum] of RDT test kit and pharmacist time spent in administering the test were US$0.15 [US$0.13–US$0.17] and US$0.41 [US$0.18–US$0.52], respectively. BCR of test-based malaria treatment was 6.7 (95% CI 6.4–7.0).

Conclusion

Test-based malaria treatment is cost-beneficial for pharmacy practitioners. This finding could be used as an advocacy tool to increase community pharmacists’ interest and uptake of test-based malaria treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1648-0) contains supplementary material, which is available to authorized users.

Overdiagnosis and overtreatment of malaria in children in a secondary healthcare centre in Sekondi-Takoradi, Ghana

Overdiagnosis and overtreatment of malaria is a major problem in children in malaria-endemic countries. This retrospective study identified children who were admitted with fever and were treated with or without anti-malarial medications and discharged at the Paediatric Unit of the Effia-Nkwanta Regional Hospital. The medical records of all children were searched, retrieved and assessed. A total of 1160 records from children (age range, 0–12 years) were reviewed and evaluated. Of the total number, 21.3% had laboratory confirmed malaria, 38.4% were malaria negative, while 40.3% had no malaria tests performed. In addition, the results showed that 4.5% of the laboratory confirmed malaria positive cases were not given anti-malarial medication while 84.1% of the malaria negative cases were given these incorrectly. Furthermore, 78.2% of the children with no malaria tests were prescribed anti-malarial medication. The presumptive diagnosis of malaria should be abandoned and the installation of a functional laboratory services promoted.

Comparison of malaria diagnostic methods in four hospitals in the Volta region of Ghana

Background

Rapid diagnostic tests (RDTs) and microscopy are routinely used for the diagnosis of malaria in Ghana. DNA-based polymerase chain reaction (PCR) is not yet used routinely. We compared diagnostic methods and tested the sensitivities of different malaria diagnostic methods against PCR.

Materials and methods

Study participants from four hospitals with a suspicion of malaria donated finger -prick blood for RDT and blood film examination. In addition, a blood spot was collected for PCR analysis, prior to treatment. Retrospective species-specific PCR was performed on all samples collected.

Results

Using PCR we found an overall malaria prevalence of 39% among the 211 evaluable blood spots (83/211) and this ranged between 6-61% across the four hospitals. Of the 164 participants with RDT data, malaria prevalence was 57% (94/164), ranging from 3-100% from the four hospitals. Microscopy was the least sensitive with a parasite prevalence of 21% (25/119) of the evaluable 119 participants, varying from 9 to 35% across three health facilities. By comparison, we found the sensitivities and specificities of RDT results when compared to PCR to be slightly higher than microscopy compared to PCR. These were 56.4% versus 41.7% and 90% versus 81.9%, respectively, but generally lower than expected. Ninety-five percent of the PCR-detected infections were P. falciparum, while 4% were mixed species infections of P. falciparum and P. malariae, with the remaining being a mono-infection of P. malariae.

Conclusions

While using PCR as a gold standard, we found RDT to be more reliable in diagnosing malaria than microscopy. In addition, a majority of malaria-treated cases were not supported by PCR diagnosis, leading to possible overtreatment. Pragmatic strategies are needed to ensure suspected malaria cases are accurately diagnosed before treatment.

Plasmodium falciparum histidine rich protein-2 diversity and the implications for PfHRP 2: based malaria rapid diagnostic tests in Ghana

Background

Malaria rapid diagnostic tests (RDTs) play a key role in malaria management and control. The PfHRP-2 based RDT is the most widely used RDT for malaria diagnosis in Ghana. Deletion of pfhrp2 in Plasmodium falciparum parasites affect the diagnostic accuracy of PfHRP-2 based RDT kits. Identifying the prevalence and distribution of P. falciparum parasites with deleted pfhrp2 is important for malaria control.

Aim

The purpose of this study was to identify and confirm the prevalence of pfhrp2 deletant P. falciparum parasites circulating within different regions of Ghana.

Methods

DNA was extracted from the membrane of spent CareStart™ PfHRP-2 RDT kits and dried filter paper blood blots using Chelex-100. Exon 2 of pfhrp2 and pfhrp3 genes were amplified by polymerase chain reaction (PCR), resolved by agarose gel electrophoresis and visualized under UV light.

Results

Microscopic analysis of blood smears from samples that were PfHRP-2 RDT positive revealed a parasite prevalence of 54/114 (47.4 %) and 2/26 (7.7 %) in Accra and Cape Coast, respectively. PCR analysis increased parasite prevalence in the RDT positive samples to 94/114 (82.5 %) and 6/26 (23.1 %) in Accra and Cape Coast respectively. The exon 2 of the pfhrp2 gene was deleted in 18/54 (33.3 %) of the microscopy confirmed and 36.2 % (34/94) of the PCR confirmed RDT positive samples collected in Accra. No RDT sample, confirmed to contain parasites by either PCR or microscopy was negative by pfhrp2 exon 2 PCR in Cape Coast. A survey of an additional 558 DBS revealed that 22.4 % (46/205) and 40 % (44/110) of PCR positive samples in Accra and Cape Coast, respectively, lacked the exon 2 region of pfhrp2 and possibly the entire pfhrp2 gene.

Conclusions

A high number of P. falciparum parasites, which lack pfhrp2 exon 2 gene have been identified in two communities in Ghana. Continuous nationwide monitoring of the prevalence of pfhrp2 deletant parasites would be essential to malaria control. The use of RDT kits that are effective at malaria diagnosis despite deletion of pfhrp2, such as the PfHRP-2/PfLDH combo RDT kit could enhance the diagnosis of clinical malaria in Ghana.

Characteristics of asymptomatic Plasmodium spp. parasitaemia in Kwahu-Mpraeso, a malaria endemic mountainous district in Ghana, West Africa

Background

Malaria control efforts in Ghana have reduced the countrywide average malaria prevalence from 71 % in 2000 to about 51 % in 2012; however, its main focus is on symptomatic malaria. If further progress is to be made, parasite reservoirs in asymptomatic carriers need to be moved into focus. This study profiles asymptomatic Plasmodium spp. parasitaemia amongst residents of mountainous Kwahu-Mpraeso in the Eastern region of Ghana.

Methods

A cross-sectional study of 360 residents was carried out from October to December 2013. This included recording demographics, malaria testing of asymptomatic residents, and gathering of their malaria history. Assessment of malaria transmission was done with molecular identification of vectors, determination of sporozoite rate, insecticide resistance status and biting pattern. Univariate and multivariate analysis were used to establish risk determinants.

Results

In Mpraeso, in the Kwahu highland of Eastern Region, children were at higher risk of asymptomatic parasitaemia, thereby contributing to the parasite reservoir and hence sustained malaria transmission. As well, findings suggested Hb AC genotype influenced susceptibility to asymptomatic malaria with 8.03-fold increase in odds (univariate) and 11.92-fold higher odds (multivariate) than the normal Hb AA. The mosquito vector predominant in the area was Anopheles gambiae sensu stricto of the homozygous pyrethroid resistant form (RR); with biting mainly occurring indoors.

Conclusion

For an effective malaria control in this area, interventions should be formulated and implemented to target asymptomatic parasite reservoirs; especially in children and people with Hb AC. The dominant vector species An. gambiae s.s. and its feeding patterns of biting indoors should also be considered.

Use of Antimalarial in the Management of Fever during a Community Survey in the Kintampo Districts of Ghana

Background

Epidemiology of malaria and related fevers in most parts of Africa is changing due to scale up of interventions such as appropriate use of ACTs in the effort towards sustained control and eventual elimination of malaria. The use of ACTs in the management of malaria-associated fever was evaluated in the Kintampo districts of Ghana.

Methods

Household survey was conducted between October 2009 and February, 2011. A random selection of 370 households was generated from 25,000 households existing within the Health and Demographic Surveillance Systems in Kintampo, Ghana at the time. All household members present at the time of survey in the eligible households were interviewed based on a two weeks reported fever recall and the use of antimalarial for the management of fever. A finger-prick blood sample was also obtained from each member of the household present and later examined for malaria parasites using microscopy. Descriptive analysis was performed, with univariate and multivariate analysis used to identify predictors of fever and malaria parasitemia.

Results

A total of 1436 individuals were interviewed from 370 households. Overall, fever prevalence was 23.8% (341/1436) and was 38.8% (77/198) in children < 5 years, 21.3% (264/1238) in older children plus adults. Participants who sought treatment for fever were 84% (285/341) with 47.7% (136/285) using any anti-malarial. Artemisinin-based Combination Therapy use was in 69.1% (94/136) of cases while 30.9% used mono-therapies. Malaria parasitaemia rate was 28.2% (397/1407).

Conclusion

The study reports high community fever prevalence, frequent use of antimalarials for fever treatment and relatively high use of mono-therapies especially in children < 5 years in an area with high malaria parasite prevalence in Ghana.

Rural-Urban Differences in Household Treatment-Seeking Behaviour for Suspected Malaria in Children at Bata District, Equatorial Guinea

Background

Malaria remains a major cause of morbidity and mortality among children under five years old in Equatorial Guinea. However, little is known about the community management of malaria and treatment-seeking patterns. We aimed to assess symptoms of children with reported malaria and treatment-seeking behaviour of their caretakers in rural and urban areas in the Bata District.

Methodology

A cross-sectional study was conducted in the district of Bata and 440 houses were selected from 18 rural villages and 26 urban neighbourhoods. Differences between rural and urban caregivers and children with reported malaria were assessed through the chi-squared test for independence of categorical variables and the t-Student or the non-parametric Mann-Whitney test for normally or not-normally distributed continuous variables, respectively.

Results

Differences between rural and urban households were observed in caregiver treatment-seeking patterns. Fever was the main symptom associated with malaria in both areas. Malaria was treated first at home, particularly in rural areas. The second step was to seek treatment outside the home, mainly at hospital and Health Centre for rural households and at hospital and private clinic for urban ones. Artemether monotherapy was the antimalarial treatment prescribed most often. Households waited for more than 24 hours before seeking treatment outside and delays were longest in rural areas. The total cost of treatment was higher in urban than in rural areas in Bata.

Conclusions

The delays in seeking treatment, the type of malaria therapy received and the cost of treatment are the principal problems found in Bata District. Important steps for reducing malaria morbidity and mortality in this area are to provide sufficient supplies of effective antimalarial drugs and to improve malaria treatment skills in households and in both public and private sectors.