INDEX

Introduction
Need Of The Study
Review Of Literature
Statement Of The Problem
Objectives Of The Study
Hypothesis
Methodology
Discussion
Study Limitations
Conclusion
List Of References

INTRODUCTION

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

present in over 100 countries. Malaria is spread by the female of the Anopheles
species of mosquito. When one of these mosquitoes bites you, it feeds on your
blood and injects malaria parasites into your body. It only takes one bite to infect
you. In some forms of malaria, parasites can stay dormant in your body for years,
occasionally "waking up" and causing you to have more attacks of malaria.
However, you cant catch malaria from another person, just from a mosquito.

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There are four types of malaria:

1. Plasmodium falciparum

2. Plasmodium vivax

3. Plasmodium ovale

4. Plasmodium malariae

The four types of plasmodium parasite include:

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

predominantly found in Africa. This parasite causes the most severe
symptoms and results in the most fatalities.

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

produces less severe symptoms than plasmodium falciparum, but can stay in
the liver for up to three years, which can result in relapses of the condition.

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

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

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

only found in West Africa.

Theyre all dangerous, but Plasmodium falciparum is considered to be the most

serious. Its responsible for most malaria fatalities. It can sometimes take a year or
more for symptoms of Plasmodium vivax and ovale to appear, while Plasmodium
falciparum usually starts within three months of being bitten.
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Occasional isolated outbreaks have been reported in England, particularly by
airport workers, and those who have contact with items imported from other
countries. Altogether, around 2,000 cases of malaria are brought into the UK each
year.

Malaria predominantly affects countries in Africa, South and Central America, Asia
and the Middle East. The disease is particularly widespread in sub-Saharan Africa,
where over 90% of malaria-related deaths occur.

Almost two thirds of all malaria-related deaths occur among the poorest 20% of the
world's population.

In 1998 the World Health Organisation (WHO), UNICEF, World Bank and the
United Nations Development Programme (UNDP) joined forces to fund the Roll
Back Malaria programme. Roll Back Malaria aims to halve malaria-related deaths
by 20101.

Symptoms of malaria tend to appear between 10 days to 4 weeks after the initial
bite. However, in some cases, depending on the type of parasite you are infected
with, it can take a year before your symptoms start to show.

Preventing mosquito bites

Below are a number of measure that you can take to help prevent being bitten by
mosquitoes while travelling in countries where there is a risk of malaria.

Use insect repellent on your skin and in sleeping environments. The most
effective repellents contain diethyltoluamide (DEET). Insect repellents are
available in a variety of forms including, sprays, roll-ons, sticks, plug-in
devices and creams.
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 Wear trousers, rather than shorts, and shirts that have long sleeves. This is
particularly important during early evening and night time, as this is the
mosquitoes preferred feeding time.

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

addition to this (or if this is not possible), sleeping under a mosquito net that
has been treated with insecticide will help you to prevent being bitten.

It is very important that you are aware that any flu-like illness, or anaemia, that
occurs within three months of returning from travelling in places where malaria is
present, may be malaria, even if you took your medicine. If you become ill when
you get back, you should see your GP and mention where you have been on
holiday, and that you may have been exposed to malaria

Prevention is better than cure

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

freedom from physical disease or pain. It is greatly affected by the surrounding
environment, the impact of environment on health has been realized since this
times immemorial. People have been taking various steps to modify their
environment to promote healthy living but certain health problems are still
dominant and constitute major public health problems especially communicable
disease.

Among the many health problems in India, communicable diseases are the
major health problem which are transmitted to man by direct and indirect contact
with the causative agent . the diseases which are indirectly transmitted by
mosquito are dengue, malaria, filaria and Chikungunya among these disease
Malaria is one of the common disease in the community.

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 Malaria has been a major public health problem, was recognized by Roman
and Greeks who associated it with swampy areas, They postulated that
intermittent fever were due to the bad odour coming from the marshy areas and
thus gave the name malaria (mal=bad+air) to intermittent fever . Inspire of the
fact that today the causative organism is known the name has struck to this
disease.

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

plasmodium falciperum, plasmodium vivax , plasmodium malaria, plasmodium
ovale, which are transmitted exclusively through the bit of infected Anopheles
mosquitoes. the intensity of transmission dependence on factors related to the
parasite , the vector, the human host , the environment, and the climatic conditions
that may affect the abundance and survival of mosquitos such as rainfall
patterns ,temperature and humidity with the peak during and just after the rainy
session. The disease is characterized by fever with chills or rigor, headache,
vomiting fatigue and other flu like symptoms , these symptoms will appears seven
days or more after the infective mosquito bite, it is diagnosed by blood test and
can be treated with anti malarial drugs.

Malaria can be prevent by combination of following measures ,

The source reduction method includes filling of breeding places, proper covering
of the stored water & insecticidal spraying.
The mosquito avoiding measure are like use of mosquito repellent liquids, coils ,
mats, screening of the houses with insecticide, and wearing cloths that cover the
maximum surface area of the body .
Early detection of the cases and treating with chemoprophylaxis.5

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 Health education at primary level of prevention aim to prevent the
malaria .it helps in reducing the morbidity and ,mortality of malaria. It also helps
in improving the knowledge of the community people related to malaria
.community health nurse play a major role in preventing the various disease in the
community by delivering health education.

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

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

cases are generated in an area where boundaries of four districts meet. These
districts, with high risk Primary Health Centres(PHC) are Chikmangalur (PHC
Kadur), Chitradurga (PHC Hosdurga), Hassan (PHC Arsikere) and Tumkur (PHC
Chikanayakanhalli).

In Tumkur district, 4 Talukas constitute high risk and problem areas. These are
(a) Sira, Chikkanayaakanalli, (b) part of Tiptur, (c) Kyathsandra of Tumkur, and (d)
part of Gubbi. Anaphelus culicifacies (species A) and Anaphelus fluviatilis (species
S) are the two malaria vectors of malaria. The major vector breeding sites are: 4
dams, 26 712 tanks, 16 943 wells, 55 852 bore wells and rain water collection sites.

In Tumkur, about 3 000 malaria cases are reported annually; of which 15-
20% constitute Plasmodium falciparum. Malaria API in the district ranged between
2.2 to 5.4 in the last five years. There are two general hospitals (500 beds each), 7
Taluk hospitals (50 beds each) and 28 Ayurvedic hospitals.(4)

In manifestation of severe Plasmodium Falciparum Malaria the signs may

include severe normocytic, normochromic anemia, renal failure, cerebral malaria,
acidosis, acute respiratory distress syndrome, hypoglycaemia, jaundice,
hyperparasitemia, disseminated intravascular coagulation(DIC), haemoglobinuria
convulsions and shock.(1)
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 The hepatorenal parameters indicating poor prognosis in severe malaria are
elevated serum creatinine >3 mg/dl, total bilirubin > 3mg/dl, elevated liver
enzymes (aspartate transaminase/ alanine transaminase >3 times upper limit of
normal). Malaria affects kidneys leading to both tubulointerstitial damage as well
as glomerulonephritis. Acute renal failure due to acute tubular necrosis occurs in
falciparum malaria. Glomerulonephritis in malaria is due to plasmodium malariae .
Though nephrotic syndrome is commonly associated with Plasmodium malaria it
can also be seen with other malarial species. Renal impairment is common with
adults with severe Plasmodium falciparum malaria, most commonly presents as
acute renal failure. Hepatic involvement commonly presents as jaundice which can
be due to intravascular haemolysis of the red blood cells(RBC), DIC,
microangiopathic haemolysis and malarial hepatitis.

The haematogical parameters indicating poor prognosis are leucocyte count

> 12,000/microl, severe anemia (Haemoglobin < 5gm/dl) and coagulopathy
(1).Common hematological abnormalities seen are anemia, thrombocytopenia with
coagulopathy. Pancytopenia reflects hypersplenic state in malaria due to increased
peripheral destruction of all cell lineages.

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

cases in our locality, it is ideal for a study to be conducted here, to know the
hepatorenal and hematological profile, and hence the degree of complication that
can arise from these deranged parameters .No study has been undertaken in this
area involving all the three parameters. Hence this study is being undertaken.

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 NEED OF THE STUDY

Much of the ill health in India is due to poor environmental health in term
of unprotected water, air pollution ,soil pollution ,poor housing, vectors around us,
high death and morbidity rate are due to poor environmental sanitation, which
needs improvement in the battle of prevention of diseases and promotion of
community health.

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

people live. According to family survey (2001) carried out by Indian Government,
found that only 19% of rural population live in Pucca house, while remaining are
living in semi-pucca, kacha house with mud walls and thatched roofs, un hygienic
conditions of housing and Rugs in open space of houses act as reservoir of
collection of water which can cause breeding mosquitoes causing life threatening
diseases such as chickungunya ,dengue, filaria and Malaria.

Disease produced by arthropods constitute major health problem in rural

and urban. Arthropods comprise varied living thing in the surrounding man. It is
estimated that about 300-500 million cases of malaria occur each year world wide,
the problem of malaria can be divided into rural, urban and tribal malaria, Rural
malaria contribute to 47.4% , tribal belt to 42% and urban malaria to 10.6%.

All the countries of the region except Maldives have indigenous malaria
transmission . An estimated 1.3 billion people or 85% of the total population are at
risk of malaria . 30% of this population live in areas with moderate to high risk of
malaria mainly in India.

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 The burden of communicable dieses is no less in our country;
communicable diseases constitute 30% of deaths in the country more than 1.5
million people suffer from malaria. In an analysis of emerging infectious disease
between 1904 to 2004 it has been observed that the majority of 80% ,are caused
by vector born dieses are responsible for 23% of them .

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

incidents of Malaria is more in rural, about 7% of the household also reported
Malaria, which is very common dieses in rural areas due to lack of drainage
facilities

It has been reported in 2001 Karnataka population census , Gulbarga

District is primarily a rural district 72% of total population lives in rural areas and
literacy level among these people is 42.28%.

In the year 2002, oxford university team at the welcome trust research
laboratory in Kenya created an extraordinary world map of malaria suffers. It is
said that there were 300-600 million clinical cases of malaria identified in world
and 1.84 million cases from India, and 132609 were reported from Karnataka.

In the year 2003, WHO burden report in India said it has 1.87 million cases
of malaria among these 0.86 million (45.85 %) are P,falciparum and the API rate
was 1.82 and there was 1006 death also reported .

In the year 2006, a total of 1.79 million cases of malaria form India and
62864 cases of malaria were reported from Karnataka state, among these 16446
cases of P. falciparum , and 29 deaths were reported from the Karnataka.

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 In the year 2010, a total of 92, 81,666 Blood slide are examined, and 44,319
cases of malaria were reported from Karnataka, of the 7936 cases were
P.falciparum and 11 deaths was reported.

During the community posting in village researcher found that the residents
of their study area are generally ignorant about the prevention of malaria, there
were no houses found to be having mosquito mesh on their doors & window,
many are storing water in open container and water tanks are also left opened. It is
found that environmental condition in nandoor village is poor and people living in
the area are more prone to get infections not only malaria but from other vector
born diseases, so researcher felt the need to conduct a study on malaria among
adults which help them to gain more knowledge about the disease condition and
its prevention.

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 REVIEW OF LITERATURE

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

critical review of scholarly publication, unpublished scholarly print material,
audiovisual materials and personal communications.

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

published scholarly literature on a particular topic . this helps in investigator to
find out what is already known and what problem remain to be solved , since
effective research is based on past knowledge , this exercise provides useful
hypothesis and helpful suggestions for significant investigations.

A prospective study was conducted by Fernando D, De silva D , et al (1999)

in a malaria-endemic area of srilanka to determine the short term impact of an
acute attack of malaria on the cognitive performance of 648 school children
divided into three group in such as , children with malaria , children with non-
malarial fever and healthy control . cognitive performance in language and
mathematic at the time of presentation and two week later were assessed . at the
time of presentation , children with malaria scored significantly less in both
mathematics and languages than children with non-malarial fever and controls .
two week later , the mathematics and language scores of children with malaria
improved . but the scores were significantly lower than the scores of children with
non-malarial fever (p<0.001) and control s (p0.001). these finding suggest that an
acute attack of uncomplicated malaria causes significant short term impairment of
cognitive performance. The impairment persists for more than two week and
appears to be cumulative with repeated attacks of malaria.

A study were carried out in 2009 and 2010 by Rehman AM, et al in Bioko
Island, Mainland quaterial Guinea and Malavia to monitor infection with

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 plasmodium falciparum in children mosquito net use. Net condition and spray
status of houses nets were classified by their condition. The association between
infection and coverage of interventions was investigated. The result suggest that
there was reduced odds of infection with plasmodium falciparum in children
sleeping under ITNs (insecticide treated nets), that were intact (odds ; ratio(or);
0.65 that is 95% . CI : 0.55-0.77 and OR ;0.81,95% CI :0.56-1.18 in Equatorial
Guinea and in Malawi respectively ) but the protective effect become less with
increasingly worse condition of the net. There was evidence for a linear trend in
infection per category increase in deterioration of net .
WHO in 2009repoted that prevention of malaria focus on reducing the
transmission disease by controlling the malaria bearing mosquitoes. The two main
interventions for malaria control are:

Use of mosquito nets treated with long lasting insecticides, a long lasting effective
method
Indoor residual spraying of insecticides.16

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

delta-methrin impregnated mosquito nets on malaria incidence, mosquito density
any adverse effect along user and collateral effects on bed bugs and house flies. A
field trial was carried out over a period of 3 years in 2 adjacent military stations,
keeping one as atrial and other as a control station . During 1st year baseline data
were collected, and during next two year residual spray was replaced with use of
deltamethrin impregnated mosquito nets in trial station. The use of deltametrin
treated bed nets resulted in a significant decline in malaria incidence and annual
parasite index (API).

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

programme for bio environmental control of malaria through folk theater
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(kalajatha) in rural India , this study was carried out under the primary health care
system involving the local community and various potential partners. Impact of
this program was assessed after two months on exposed Vs non-exposed
respondents. The result suggest that the exposed had significant in knowledge and
change in attitude about malaria and its control strategies, especially on bio
environmental measures (p<0.001).they could easily associate clear water with
anopheline breeding and role of larvivorous fish in malaria control which
subsequently resulted in reduction of malaria cases.

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

the extent to which the primary health care services have contributed to reducing
the burden of malaria since the system was initiated in the 1980s. it covered house
hold interviews with a stratified sample of 1250 respondent, and in death
interviews with all 175 health care providers in the 35 health facilities with in the
district, The average number of clinical ,malaria episodes per child below 5 years
of age remained between 3 and 3.5 episodes per year in the district since the 1960s
.the comparison of cases expected in the population less than 5 years old with
those seen the district heath facilities shows a coverage rate of 33% . Furthermore,
between 1990 -2003, a little training on malaria was provided to health staff. The
findings imply a limited effectiveness of district health services on malaria
control.

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

is anti-malarial drug resistance enhances towards increasing mortality, and
economic and social cost. He found that combination therapy is better than mono
therapies in controlling malaria.

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 It was reported that malaria can be prevented by mosquito screening,
protective clothing ,insect repellants, by health education, case finding
,chemoprophylaxis by chloroquine , myloquine , proguanil , doxycycline ,
chloroquine co administered with proguanil.

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

determine the effectiveness of space of insecticides for the control of malaria in
Ranau , a distric in sabah. This study does indicate that space application of
larvicides adulticides or a mixture of both is able to reduce the malaria vector
population and the malaria transmission. A larger scale study needs to be
undertaken in a malaria-affected villages / province to determine whether space
application of insecticides together with other malaria control measures will be
able to eradicate malaria.

A cross sectional study was conducted to determine the availability and

utilization of malaria prevention strategies in pregnancy among 260 antenatal
mothers in Jharkhand and Chhattisgarh, India. The result reveals that in Jharkhand
90 %pregnant women used bed nets in the house and in Chhattisgarh the rate was
40 % where Asante malaria chemo-prophylaxis was less than 1 % hence the
researcher concluded that a target increase of educational effort should be made
among antenatal mother for the prevention of malaria.

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

determinations of hospital stay among malaria patients at a tertiary care hospital
Goa. Out of 748 patients admitted with malaria in the hospital, 77.4% (579 /748)
were male and 22.6% (169/748)females. among all patients 14.2% (106-748)had
Vivax , 63.4% (474/748) falciparum and 22.4% ( 168/748)had mixed malaria
infection .in this study 78.3% (586/748)patients improved ,2.5% (19/748)died and

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

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

risk rural areas of vadodra district was evaluated,from 269 high risk villages . 20
villages were selected randomly from 10 taluks, the monthly blood examination
rate ( MBER)targets could not be achived in 8 out PHCs the performance of 50%
of malaria clinics and 94% of the village was poor to average , the study has found
that there were lapses in the operation of the NAMP.

Malaria is the most important protozoal parasitic disease of humans

affecting more than 1 billion people world wide and causing 1-3 million death each
year. (1)The word malaria derives its origin from the Italian mal-aria meaning
bad air.

Charles Louis Alphonse Laveran, a French army surgeon stationed in

Constantine, Algeria, was the first to notice parasites in the blood of a patient
suffering from malaria on the 6th of November 1880. For his discovery, Laveran
was awarded the Nobel Prize in 1907.On August 20th, 1897, Ronald Ross as the
first to demonstrate that malaria parasites could be transmitted from infected
patients to mosquitoes.

In India, formal malaria control programmes were started under British

colonial rule and continued after Indian Independence in 1948. Early malaria
control efforts involved removal of breeding sites and later used chemicals such as
the larvicides Paris green and kerosene. In 1946, pilot schemes using DDT were set
up in several areas, including Karnataka. Usefulness of DDT prompted the launch
of the National Malaria Control Programme (NMCP) in 1953. The programme saw
tremendous impact and the annual number of cases came down to 49151 by 1961,

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with a belief that malaria could be eradicated in seven to nine years. On the
contrary, malaria began to re-emerge in 1965. With increase in malaria cases in
urban areas, The Urban Malaria Scheme (UMS) was launched in 1971. In 1977 the
Modified Plan of Operation (MPO) was launched. The National Anti Malaria
Programme (NAMP) was launched in 1995. In 2004, the integrated National
Vector Borne Disease Control Programme (NVBDCP) for the prevention and
control of vector borne diseases was launched. Despite all these measures malaria
still prevails causing significant morbidity and mortality.

Causes of anemia in malaria are- hemolysis of infected RBCs, hemolysis of

non infected RBCs [black water fever],dyserthryopoesis, splenomegaly and folate
depletion.

Renal dysfunction can also arise due to hemoglobinuria [black water fever] ,
oliguria and anuria due to acute tubular necrosis.(7)Nephrotic syndrome is seen in
plasmodium malariae infection.(7) Plasmodium malariae infection is prevalent in
tumkur.(3) Renal dysfunction usually resolves , urine flow resumes in a median of
4 days and serum urea creatinine returns to normal in a mean of 17 days.

Hepatic involvement manifests commonly as mild hemolytic jaundice.

Severe jaundice can be seen due to hemolysis, hepatocyte injury and
cholestasis .When compared to other vital organ dysfunction, liver dysfunction
carries a poor prognosis.Another study has also shown that liver involvement has
poor outcome.

Hence this study is conducted to study the derangement in biochemical

parameters and its correlation with outcome of disease.

A study conducted by Lon et al between January 2006 and June 2009, a total
of 537 records from suspected severe malaria cases were reviewed from patients
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admitted or discharged from BRH (Battambang Referral Hospital) with a diagnosis
of severe malaria. After review by study physicians, 393 patients met published
Cambodian severe malaria case definitions and were considered to be probable
severe malaria cases. 217 P. falciparum (81.9%), 33 P. vivax (12.4%); and 15
documented mixed infections (5.7%) positive for both P. falciparum and P. vivax.
In patients who met the severe malaria case definition (all age groups), the most
common clinical features included prostration (68%), impaired consciousness
(65%), and respiratory distress (48%), and all three were associated with a
substantially increased risk of mortality in a univariate analysis. Circulatory
collapse (15%), renal failure (27%), and pulmonary oedema (2%), though less
common, were also associated with increased mortality. In multivariate analysis,
only circulatory collapse and renal failure remained statistically significantly
associated with a higher mortality risk independent of age.

A study was conducted at the Outpatient Department of Ebonyi State

University Teaching Hospital, Abakaliki where Seventy-four (20.3%) of the
patients had Plasmodium falciparum malaria. Although all the urine parameters
were higher in the malarial patients in comparison to the control, only bilirubinuria
and urobilinogenuria were statistically significant (p <0.05). Also, bilirubinuria,
urobilinogenuria, haematuria and proteinuria were significantly (p <0.05) higher in
P. falciparum infection than in infections with other malaria species, but only in P.
falciparum infection, bilirubinuria and urobilinogenuria were significantly (p
<0.05) higher at higher parasitaemia

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

acute kidney injury (AKI) occurred in 63 patients (32%), with maximum RIFLE
class R(Risk), Class I (Injury) and class F (Failure) in 27 (43%), 23 (37%) and 13
(21%) patients, respectively. AKI was associated with oliguria/anuria (48%),

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anaemia (70%), thrombocytopenia (84%), hepatic dysfunction (48%),
gastrointestinal manisfestations (33%), ARDS (14%), cerebral malaria (6%), DIC
(8%), and shock (11%). Patients with maximum RIFLE class R, I and F had
mortality rates 3.7%, 4.3%, 30.7% respectively.

Thrombocytopenia and platelet dysfunction is the two most important changes

seen in malarial infection.
The mechanism of thrombocytopaenia in malaria could be due to peripheral
destruction and consumption by disseminated intravascular coagulation(DIC).
Thrombocytopenia is seen 40-90 percent of patients infected with P. Falciparum
infection in India.
The above percentage being obtained from 2 studies, one done in a tertiary care
hospital to study the clinical profile of Falciparum malaria on 158 consecutive
cases of Falciparum malaria, and the other study being done on 162 patients
including both Vivax and Falciparum malaria infected cases, to study
thrombocytopaenia and prolonged bleeding time in patients with malaria.
Erythrocytes containing mature parasites may activate the coagulation cascade
directly and cytokine release is also procoagulant.
Malaria is a protozoal disease caused by infection with parasites

of genus Plasmodium and transmitted by infected female Anopheline

mosquito. The various host factors influencing malaria transmission

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

immunity. Environmental factors like season, temperature, humidity,

rainfall, and altitude also influences the malaria transmission. The

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

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

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genetic factors. Severe complicated malaria is most commonly seen in

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

Severe malaria is defined according to the WHO guidelines. The

presence of one or more of the following clinical or laboratory

features classifies the adult patient as suffering from severe malaria.

Clinical features like a) impaired consciousness or unrousable coma,

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

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

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

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

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

hemoglobinuria, h) abnormal spontaneous bleeding, i) pulmonary

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

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

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

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

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

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

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

Thrombocytopenia by definition is an abnormally low amount of

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

associated with abnormal bleeding. It results from various factors like

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platelet activation, splenic pooling, dyspoietic process in the marrow

with diminished platelet production and reduced life-span due to

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

their study have found Thrombocytopenia is not a distinguishing

feature between type of malaria but severity of thrombocytopenia

differ between the type of malaria.

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

Both spleen rate and average enlarged spleen are useful indicators of

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

their study have found in vivo ultrasound measurement of splenic

length with the patient in right lateral decubitus position correlates

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

than 12cm in 95% of the normal adult population

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

acute renal failure (ARF), determine oxidative stress as well as to predict the
outcome in patients with severe falciparum malaria (FM), which included a total of
75 subjects; there were 25 adult patients with acute severe FM and ARF, 25 adult
patients with uncomplicated FM without ARF, and 25 age- and sex matched
healthy subjects as controls. In patients with severe FM and ARF, renal failure was
non oliguric in 28% and oliguric in 72%. The average duration of renal failure was
10.53+4days. 60 % recovered and 40% died. All patients with non-oliguric
presentation recovered. The Acute Physiology Age and Chronic Health Evaluation
II (APACHE II) score, Sequential Organ Failure Assesment (SOFA) score, and

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Acute Tubular Necrosis-Individual Severity Index (ATN-ISI) score were all
significantly higher in the expired group when compared to the survivor group.
Kaplan-Meir survival analysis showed that survival was low in patients with
delayed hospitalization and longer duration of symptoms

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STATEMENT OF THE PROBLEM

A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE

REGARDING PREVENTIVE MEASURES OF MALARIA AMONG ADULT
WITH A VIEW TO DEVELOP HEALTH EDUCATION MODULE

Malaria control and interventions have been implemented and in the recent
past and intensified as an effort to attain the World Health Assembly, Roll Back
Malaria, and Millennium Development universal targets with the aim of reducing
and interrupt disease transmission in sub Saharan Africa. Kagera Region is a
malaria endemic area in which malaria control measures such as the use of
Artemisinin combined therapy (ACT), the use of insecticide treated bed nets
(ITNs), indoor residual spraying of insecticide (IRS), and Intermittent Preventive
Treatment (IPTp) for pregnant women and children have been implemented.
Despite of all these efforts yet the overall prevalence of malaria infection remains
high among the underfive children: 49-53.3%, (Mboera et a., 2006) study done in
Muleba District. This verifies that there could be several reasons for this situation
including the deficiencies in the Health system that leads to lack of access to
malaria control interventions and low effectiveness of these interventions than
expected. Thus it is very essential that operational research is conducted to
identify the gaps. Therefore this work involves a community approach first to
confirm the prevalence of malaria in under-fives, coverage of ITNs, IRS as well
assessing of malaria prevalence among the under-five children, determining the
coverage of ITN use among community members, as well as assessing the factors
(socio-economic, physical, environmental, demographic factors) associated with
malaria prevalence in Muleba district.

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RATIONALE FOR THE STUDY

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

the morbidity and mortality in under-fives is still unacceptably high. (MoH, 2006).
This study is then designed to investigate the changing epidemiological data of
malaria. The collected data will provide the understanding on the factors that
influence the high prevalence of malaria parasite among the under five years
children in Muleba District. The information that will be collected will be an
essential component in the effectiveness of Malaria control and elimination
interventions that are currently being scaled up hence it will be used to realign the
effectiveness of Malaria control measures so as to effectively reduce malaria
burden and achieve elimination.

RESEARCH QUESTIONS

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

the Community

2. What are the factors contributing to the prevalence of malaria among the under-
five In Muleba district

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

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

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 OBJECTIVES OF THE STUDY

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

adults .
2. To develop health education module regarding preventive measures of malaria
among adults .
3. To find out association between knowledge regarding preventive measures of
malaria among adults, with selected demographic variables.

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 HYPOTHESIS

Hypothesis is a statement of predicted relationship between two or more

variables in a research study.

There will be a significant association between the knowledge score of

adults on the preventive measure of malaria and selected variables such as age ,
religion, education , monthly income , drainage system and environment.

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 OPERATIONAL DEFINITIONS:

Knowledge : It refers to the knowledge regarding

preventive measures of malaria among the adults.

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

Assess : It refers to statistical measure of knowledge

on prevention of malaria among adults of rural
village using structured knowledge of
questionnaire.

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

age group of 20 to 59year living in nandoor ,
Gulbarga district.

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

causes , signs and symptoms, Management and its
prevention.

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 8. MATERIALS AND METHOD

8.1 SOURCE OF DATA

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

8.2. MATHOD OF COLLECTION OF DATA
SAMPLING CRITERIA:

Inclusion criteria:
The study includes adult people, who are,
1. Available at the time of study.
2. Willing to participate in the study.
3. Can understand Kannada and Hindi.

Exclusion criteria:

The study excludes adults people who are ,

1. Not willing to participate in the study.

2. Cannot understand Kannada and Hindi.
3. Not available at the time of study.
4. Vision and hearing problems.

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 METHODOLOGY

Study Design

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

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

Description of the Study Area

This study was conducted in Kagera region, with a focus on Bareilly district.
Bareilly district was selected purposively as it is one on malaria endemic
areas.Bareilly District (145'N, 3140'E) is in the North-western part of Tanzania
with an area of 10,739 km2 , of which 62.0% consists of Lake Victoria. Most
parts of the district lie at 1200-1500 m above sea level. Administratively the
district has 5 divisions, 31 wards, and 134 villages. It has a population of 425,172
people with 85,035 (20%) being children under the age of five years with the
majority being the Haya. The district has 36 health facilities, 3 of them being
hospitals (Rubya, Kagondo and Ndolage). Others are health centres (4) and
dispensaries (29). The district has two rain seasons which occur in March - June
and September-December during which malaria transmission peaks. Agriculture
is the main economic activity in the Bareilly district. The main food crops grown
include banana and beans, while less important ones include maize, cassava,
sorghum, groundnuts, sweet potatoes, rice plant and yams. Cash crops include
coffee, cotton, and tea. Fishing is another important activity, particularly for
villages adjacent to the Lake Victoria shore; e.g., Nshambya village in Bareilly
district district.

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 Health information:

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

transmission of varying seasonality. The highest peak of malaria transmission is
usually reached between May - July and November-January, which results from
proceeding rain seasons The first most devastating malaria epidemic occurred in
1997/98 following the EL- Nino rains. The district experienced another malaria
epidemic in recent years (2006). The government responded to the epidemic by
changing the first line antimalarial drug from sulfadoxine-pyrimethamine to
artemether-lumefantrine in Bareilly district. This was followed by introducing of
indoor residual spraying in 2007. Three hospitals and two health centers that are
found within Bareilly District, with inpatient facilities saw malaria-related
admissions and death rates in children under five years of age in 2006 and 2010
drop dramatically from 145 to 23 per 1000 (84% reduction) and from 42 to 5 per
10 000 (89% reduction), respectively. IRS results in Bareilly district were
impressive. An average of 100 000 house structures were sprayed per round in the
selected areas up to 2009 and over 200 000 house structures between 2009 and
2011, with spray coverage of targeted structures exceeding 95%.(NMCP,-country
report,2012) In the transmission season of 2011 (May-July) a number of health
facilities reported an increased number of malaria cases compared to the previous
three years. High mosquito densities were also recorded in some foci within the
district. Several factors were associated with this increase: acute ACT stock-outs
in first level health-care facilities, evidence of decreased susceptibility to the
insecticide used for IRS in localized areas, suboptimal net distribution in some
communities, and low reported net use. This event demonstrates the risk for
malaria resurgence in areas where it has been successfully controlled. %.(NMCP,-
country report,2012)

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 Study Population

The study population was divided into two groups: (1) under fives who were
checked for malaria parasites using the mRDT, (2) Head of
households/mother/guardians with underfive years children or their
representative when the head of households was not around at the time of the
study

Sampling method

Random sampling design was employed as the sampling method.

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Sampling Procedures

Study villages were selected using a multistage random sampling procedure and a
cluster sampling procedure as the final stage. Selection was made with the
assistance of village and sub village heads. In the first stage, names of divisions
were obtained from the office of DMO where by two divisions were selected
randomly out of the five division found in Bareilly district. Out of the randomly
selected divisions one ward from each division was selected randomly. A ward is
an administratively demarcated area below the district level, which may comprise
three to five villages (rural) In the third stage a list of villages found in each ward
were listed from records obtained from the district medical officer's office and
randomly two villages were selected In the fourth stage, out of the two randomly
selected villages, two sub-villages were randomly selected making a total of four
sub villages. From these list two divisions namely Bareilly and Kimwani were
randomly selected. Out of the randomly selected division two wards were
randomly selected namely Gwanseri and Kasharunga wards. Villages namely,
Kasheno, Nshambya, Nkomero , Kiteme were randomly selected. Another four
sub-villages were randomly selected from a list of randomly selected villages
namely Kimeya, Byantanzi, Kaina Kasheno, making a total of four sub villages.
With the assistance of sub village heads as well as the village health care workers,
a list of all household with under fives was made from which 16 to 20 households
per sub village were randomly selected to give an overall sample size of 391 study
participants which was considered sufficient for the study. In the fourth (final)
stage, level of parasitemia among the under-five children in the selected
households were ascertained during surveys using a rapid diagnostic test
(mRDTSD/bioline) with the aid of a well trained laboratory technician. Consent
to draw blood from the children was obtained from their parents/guardian.

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Data Collection Method

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

sociodemographic factors, knowledge about the transmission and prevention of
malaria, utilization and coverage of ITNs were administered to the 391 eligible
participants, whereby every head of the selected household either female or male
present at home was interviewed in Kiswahili language.

Parasitological based

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

surveys using a rapid diagnostic test (mRDT) with the aid of a well trained
laboratory technician. Consent to draw blood from the children was obtained from
their parents/guardian.

Data Management and Analysis

Questionnaire was checked for errors and completeness before entry into Data base
where by summary statistics sheet was analysed using SPSS statistical software,
version 16.0 Bivariate and multivariate logistic regression analysis was employed
to examine the association between socio demographic variables and other risk
factors with malaria prevalence, and the Factors associated with malaria infection
were generated from this regression. Association between proportions of the under-
five children who we tested positive and those who were tested negative was
compared using Chisquare. A p-value of less than 0.05 was considered
significant.

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Ethical Issues

Ethical clearance to conduct the study was granted by the Muhimbili University of
Health and Allied Sciences (MUHAS) research and publication committee.
Permission to conduct research was sought and granted by the Regional
Administrative Secretaries of Bareilly district. A written consent to participate was
sought from each respondent before the questionnaire was administered. Before
commencement of the study, the principal investigator and his research team
conducted meetings with local leaders and communities in all selected villages
during which the objectives of the study including procedures to be followed were
explained. Feedback to the study population was conducted in the form of
dissemination meetings after completion of the study. For those children who were
found positive were referred to the nearest health facility for the appropriate
treatment. This arrangement was done and the head of the health facility
cooperated to provide treatment.

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 DISCUSSION

This study was carried out in Bareilly District Council where the primary objective
of the study was to determine the prevalence, of malaria among the under-fives and
the associated factors. This study was done in mid April and this was a high
malaria season hence the high prevalence. The test was done using the mRDT
where by overall prevalence of malaria among the under-fives in the study area
was (26.3 %). The prevalence of other species (P.Vivax, P. Ovale, P.Malariae) were
also being observed higher (13%). This reflects that perhaps we are missing other
species with the microscopy. For the diagnosis of malaria, microscopy is
considered as the reference method, but expert microscopy may be lacking in both
endemic and non-endemic settings. In resource-poor endemic settings, there may
be problems related to equipment, expertise and workload, whereas I non-endemic
settings in industrialized countries, there may be a lack of routine among the
laboratory staff, resulting in low expertise. In these circumstances, the use of
malaria rapid diagnostic tests (MRDTs) can be valuable in the diagnosis of malaria.
MRDTs detect antigens specific to one or more of the Plasmodium species. The
prevalence of malaria infections found in this study was low as compared to a
previous study conducted in the same area of which indicated an overall
prevalence of malarial infection to be 49-53.3% in Bareilly district (Mboera et al.,
2006. However the findings were similar high when compared to the findings from
other studies carried out in developing countries. For example, Malaria has the
least prevalence, 27.6 percent, in children age 6 to 59 months in the South East
region of Nigeria. (Nigeria malaria fact sheet2010)

Furthermore it was observed that the prevalence of malaria was higher in Kimwani
division 50% as compared to Bareilly division of which was 17%. Several factors
were observed to be associated with the high prevalence, these includes:

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socioeconomic factors, physical/environmental factors of which favors the
mosquito breeding sites as well as ineffective implementation of malaria control
measures such as the use of ITNs and IRS.

Employment status of the respondents was also being observed to be one among
the possible factor that were associated with the prevalence of malaria among the
under fives during the survey. This concurred with (Makundi EA et al (2007) who
reported that the burden of malaria is greatest among poor people, imposing
significant direct and indirect costs on individuals and households and pushing
households into in a vicious circle of disease and poverty. This was also being
observed in a study done by Wandiga SO, et al. (2006.) who stated that,
vulnerable households with little coping and adaptive capacities are particularly
affected by malaria hence they can be forced to sell their food crops in order to
cover the cost of treatment.

Furthermore, according to the study findings housing and environmental factors

such as the proximity of the house to the breeding sites/ and farming activities
were found to be associated with the prevalence of malaria. This was also being
revealed in a study done by, (Lindsay SW, et al 1993) whereby it was reported
that the relationship between malaria vector density and the distance of settlement
from a water body like river is an important indicator of malaria transmission. It
was also being supported by (Shell, 1997), who reported that Certain types of
housing may influence malaria transmission. Greater exposure to the outdoors
(lack of windows or screens, for example), may increase contact between an
individual and the mosquito vector. According to the findings of the study, the
concept of using of ITNs was considered as one of the protective factor against
the mosquito bite; hence reduce the prevalence of malaria among the under-fives.
This was supported by the MoHSW (2006) report, which stated that Insecticide-

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 treated mosquito nets (ITNs) used for protection against mosquito bites have
proven to be a practical, highly effective, and cost-effective intervention against
malaria.

Despite the fact that the use of ITNs was considered as one of the protective
method, It was further being identified that the prevalence of malaria among those
who were not using the ITNs was observed high as compared to those who were
using: in Kimwani division the 70% of the surveyed households were not using
the Insecticide treated Nets Selective indoor residual spraying (IRS) remains one
of the key strategies of the NMCP, though primarily used for epidemic prevention
and response. Indoor residual spraying with insecticide has been shown to be
highly effective as a malaria control measure in reducing the incidence of malaria
infections and deaths in a number of settings. (Oaks SC Jr, et al 1991). However
the study findings supported that IRS, was associated with protection from
parasitemia in both bivariate and multivariate analysis, it was also being observed
that many of the residents who were residing in Kimwani division were migrants
who were coming for the purpose of cultivating rice plant. Due to the issue of
settlement then people were found staying in places which were not sprayed by
IRS hence this increased the chance of mosquito bites and thus the high
prevalence. Taken together, the results presented here illustrates that: ITNs use,
IRS, parents/guardians education status, economic status; physical/environmental
factors are the predictive factors of the prevalence of malaria among the under-
fives.

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 STUDY LIMITATIONS

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

regarding ownership of LLITNs

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

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

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

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 CONCLUSION

It can be concluded that bareilly district specifically kimwani divisions has the
prevalence of malaria that is more being observed among the under-fives as
compared with Bareilly Division. The higher prevalence could be the result of
several factors as explained in this study. The finding of the study reflects that if
the control measures will be implemented appropriately then the prevalence of
malaria will decrease. Carefully-coordinated surveillance and response are
required to address ongoing, low-level transmission hot spots as well as acute
outbreaks once sustained control of malaria will be eventually achieved.

RECOMMENDATIONS:

1. There is the need for a strong collaboration among major stakeholders including
the Government, District Assemblies, and Non- Governmental Organizations to
sensitize the communities on Malaria as a disease as well as developing the holistic
and effective methods for prevention and control of the disease.

2. Though the uses of IRS, LLITNs are identified as the major method of
prevention due to their availability and affordability for many households, the
implementation of these methods is still questionable. Therefore the
implementation of these methods needs to be re-assessed by concerned authorities
in order not to endanger the health of the people.

3. Efforts must be seriously made by the major players in the health sector to make
the net readily available in the communities at low prices to enable the ordinary
Tanzanians to purchase it.

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4. In order to improve timeliness of treatment, the service consequently needs to be
closer to the communities especially those found in the remote and malarious
endemic areas like Kimwani/ Kasharunga village in Bareilly district.

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