Tropical Diseases Control

ASYMPTOMATIC MALARIA INFECTION AMONG PRIMARY SCHOOL AGED CHILDREN IN MOROGORO MUNICIPAL.

ABSTRACT
Malaria is still a public health problem in Morogoro region affecting children, pregnant women and other community members including primary school children. Recent findings shows slight decline of malaria prevalence in the region from 15.7 percent to 13.7percent which is equivalent to 17.2 percent decrease low as compared to 50 percent national wide decrease (18 percent to 9 percent). However in malaria endemic countries like Tanzania, large numbers of Plasmodium falciparum infections are asymptomatic and hence are carrier and reservoir of parasites readily available for transmission by Anopheles mosquitoes. Since malaria control efforts are intensified to young African children, this lead to acquired immunity and increased risk for School age children and above. But surprisingly little is known about the burden of malaria in African school children which causes up to 50 percent of deaths in this age group, contribute to anaemia and consequences for learning and educational achievements.
Objective: The broad objective of this study is to determine the current situation on prevalence of asymptomatic malaria parasitaemia among primary school aged children in Morogoro municipal.
Methodology: This will be a descriptive cross-sectional study design. This study will recruit 350 primary school children randomly selected from 5 primary schools out of 60 public primary schools in the municipal. All selected children will be diagnosed for plasmodium parasite using mRDT; the quality control of mRDT results will be conducted using microscopy. They will be also assessed for anemia, interviewed on ITNs and ACTs usage, and recent history of illness. Socio-economic factors and demographic characteristics will be asked too. Children responses will be recorded onto the questionnaires and later entered in the SPSS data software for storage and analysis.
Budget: For the purpose of completing this research study, a total of Tshs 3,258,300/= will be required to facilitate all research requirements.
Conclusion: Since school aged children are most commonly infected with malaria parasites and they are asymptomatic and thus act as reservoir /carrier of malaria infection in the community. It also results into anemia, reduced school attendance, cognition and school performance. Therefore, the results from this study will inform decision makers to change malaria policy intervention not only to under fives and pregnant women but also to include school children. Lastly, it is known from other African countries that school malaria surveys provide a rapid, cheap and sustainable approach to malaria surveillance in the country.

TABLE OF CONTENTS
ACKNOWLEDGEMENT 1
ABSTRACT 2
TABLE OF CONTENTS 3
ACRONYMS/ABBREVIATIONS 5
CHAPTER ONE 6
1.0 INTRODUCTION: 6
1.1 Global Malaria situation 7
1.2 Malaria situation in Tanzania 8
1.3 Malaria Epidemiology in Tanzania 10
1.4 PROBLEM STATEMENT 12
1.5 RATIONALE OF THE STUDY 13
1.6 RESEARCH QUESTIONS 14
1.7 OBJECTIVES 14
1.7.1 Broad Objective 14
1.7.2 Specific Objectives 14
1.8 CONCEPTUAL FRAMEWORK 15
CHAPTER THREE 24
3.0 METHODOLOGY 24
3.1 Study Design 24
3.3 Study Population 25
3.4 Study Unit 25
3.5 Eligibility 26
3.6 Sample Size 27
3.7 Sampling Techniques 28
3.9 Data collection Techniques 29
3.12 Study Variables 30
3.14 Data Management and Analysis 31
3.15 Ethical Consideration 34
CHAPTER FOUR 35
4.0 BUDGET 35
4.1 PLAN OF ACTIVITIES 36
REFERENCES: 37
Appendix- I: QUESTIONNAIRE (English version) 41
Appendix II: QUESTIONNAIRE (Swahili version) 45
Appendix III: Field Laboratory Investigation Form. 49

ACRONYMS/ABBREVIATIONS
ACT: Artemisinin based Combination Therapy
AIDS: Acquired Immune Deficiency Syndrome
ALU: Artemether Lumenfantrine
GMP: Global Malaria Program
HIV: Human Immunodeficiency Virus
IPTp: Intermittent Preventive Treatment of malaria in pregnancy
IRB: Institution Review Board
IRS: Indoor Residual Spray
ITN: Insecticide Treated Nets
LLIN: Long Lasting Insecticidal Nets.
MDGs: Millennium Development Goals
MoHSW: Ministry of Health and Social Welfare.
MTMSP: Medium Term Malaria Strategic Plan
PCR: Polymerase Chain Reaction.
PMI: President's Malaria Initiative
RBM: Roll Back Malaria.
RCT: Community-based Randomized Controlled Trials
RDT: Rapid Diagnostic Test
SP: Sulphadoxine Pyrimethamine
TDHS: Tanzania Demographic Health Survey
THMIS: Tanzania HIV/AIDS and Malaria Indicator Survey.
UCC: Universal Coverage Campaign
WHO: World Health Organization

CHAPTER ONE
1.0 INTRODUCTION:

Malaria infection is caused by five species of parasites of the genus Plasmodium that affect humans (P.falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi). Infection due to Plasmodium falciparum is the most deadly and predominates in Africa. Plasmodium vivax is less dangerous and more widespread, other three species are found much less frequently. Malaria parasites are transmitted to human being by the bite of infected female mosquitoes. Example in Sub Saharan Africa where most of malaria cases and deaths occur, members of the Anopheles gambiae species complex and Anopheles funestus species group are the important malaria vector (WHO2012; (Kabula et al. 2011).
In malaria-endemic countries, most of the Plasmodium falciparum infections are asymptomatic. The asymptomatic carriers usually do not seek treatment for their infection and therefore, add up to a reservoir of parasites available for transmission by Anopheles mosquitoes (Kimbi 2012).
However children under the age of five years and pregnant women are the primary targets for most malaria control programs. They experience the most acute symptoms of malaria, and more likely to result into death. It is shown that, school age children are the age group most commonly infected with malaria parasites. Their infections are usually asymptomatic, go unnoticed and thus never get treated. These school age children are also least likely to sleep under a mosquito net and thereby most exposed to malaria threat and hence contribute to onward malaria transmission to other community members (Noor et al. 2009). But if untreated, these infections can result into anemia and reduced children's ability to concentrate and learn in school (Clarke et al. 2008).
The recommended malaria interventions include; (i) vector control through the use of insecticide-treated nets (ITNs), indoor residual spraying (IRS) and larval control; (ii) chemoprevention for the most vulnerable groups especially pregnant women and infants; (iii) confirmation of malaria diagnosis through microscopy or rapid diagnostic tests (RDTs) for every suspected case, and (iv) early and timely treatment with appropriate ant malarial medicines as according to the recommended WHO treatment guideline regimen (WHO, 2011).
Principally any intervention that achieves a complete blockage at any point in the life cycle of malaria parasite would effectively interrupt transmission and facilitate malaria eradication efforts. To date, no single intervention which have capacity to block all point of malaria parasite life cycle, thus until that to occurs, multiple interventions operating at various points in the life cycle of the malaria parasite will be needed to maximally inhibit progression through the life cycle and prevent transmission (Hall & Fauci 2009).
1.1 Global Malaria situation

The latest WHO estimates, shows 219 million cases of malaria in the year 2010 and an estimated of 660 000 deaths. The most affected continent is Africa of which 90% of all malaria deaths occur. Between the year 2000 and 2010, malaria mortality rates fell by 26% around the world while in African continent the decrease was 33%. During this time period approximately 1.1 million malaria deaths were averted globally, mainly as a result of a scale-up of interventions. According to the report, the six highest burden countries in the African area are Nigeria, Democratic Republic of the Congo, United Republic of Tanzania, Uganda, Mozambique and Cote d'Ivoire. These six countries account for an estimated 103 million (or 47%) of malaria cases (WHO, 2012).

The number of long-lasting insecticidal nets delivered to malaria-endemic countries in sub-Saharan Africa increased from 88.5 million in the year 2009 to 145 million in the year 2010. It is estimated that 50% of households in sub-Saharan Africa they have at least one bed net and about 96% of person have access and use it. However number of rapid diagnostic tests for malaria delivered by several manufacturers increased from 45 million in the year 2008 to 88 million in the year 2010, and the testing rate in the public sector in WHO African Region rose from 20% in the year 2005 to 45% in the year 2010. In the year 2010, approximately 181 million courses of artemisinin-based combination therapies (ACTs) were procured worldwide in the public sector, more from 158 million in the year 2009, and just 11 million in the year 2005. ACTs are recommended as the first-line treatment for uncomplicated malaria caused by Plasmodium falciparum malaria parasite species most deadly to humans. Moreover Malaria interventions are highly cost effective and inexpensive; examples a rapid diagnostic test costs US$ 0.50; a course of artemisinin-based combination therapy (ACT) costs between US$ 0.90 - 1.40 for an adult, and US$ 0.30 - 0.40 for a young child and finally long-lasting insecticidal net that lasts three years cost US$ 1.39 per person per year of protection (WHO, 2011).
Following an intensified malaria control efforts among young African children, this resulted in acquisition of exposure-dependent immunity and potentially increases the risk for children of school age and above (Bundy et al. 2000). Surprisingly little is known about the burden of malaria in African schoolchildren, but the available evidence suggests that malaria causes up to 50% of all deaths in this age group, also is an important major contributor to anaemia and may have profound consequences for learning and educational achievement (Brooker et al. 2008).
1.2 Malaria situation in Tanzania

Malaria is still a public health problem in Tanzania and the major cause of morbidity and mortality, accounting for about 30% of all hospital admissions and around 15% of all hospital deaths (Msangeni et al. 2011).
In many parts of the country, including the uplands, they report malaria transmission throughout the year, although it occurs most frequently during and after the raining season from April to May and the disease accounts for 40% of all outpatient visits (TDHS2010)
In one of the study conducted in Tanzania, they reported the disease to ranks number one in both outpatient and inpatient statistics and that; socio-economic impact of malaria is too high that contributes highly to poverty and under development (Mboera et al. 2007) and also add to school absenteeism and low productivity in the work place in Tanzania (TDHS 2010).
The number of clinical malaria cases in Tanzania per year is estimated to be 17 ' 20 million resulting into approximately 80,000 deaths. Common species of malaria parasites responsible for over 95% of malaria infections in Tanzania is Plasmodium falciparum. This parasite has developed resistance to the most commonly used ant malarial medicines in the country i.e. chloroquine and Sulfadoxine /Pyrimethamine (MTMSP 2008-2013).
In the country, the increased availability and accessibility of insecticides treated nets (ITNs) seen since a year 2004 when Tanzanian National Voucher Scheme was introduced to pregnant women and infants by subsidizing the cost of nets purchased. Furthermore from the year 2008 to a year 2010, a mass distribution campaign delivered nine million long-lasting insecticidal nets (LLINs) free-of-charge to children under-five years of age in Tanzania mainland. But in the year 2010 and 2011, a Universal Coverage Campaign (UCC) led by the Ministry of Health and Social Welfare was implemented to cover all sleeping spaces not yet reached through previous initiatives(Renggli et al. 2013).
The malaria indicator survey explains the primary objective of Roll Back Malaria (RBM) as to increase access to the most effective and affordable malaria protective measures. These measures include use of insecticide-treated mosquito nets (ITNs) and long-lasting insecticidal nets (LLINs) for sleeping and increased coverage of prompt and effective treatment for malaria. It again emphasizes artemisinin based combination therapy (ACT) as the first-line drug for treatment of malaria in both Tanzania mainland and Zanzibar. Introduction of ACT is a response to the emerging resistance of malaria parasites to ant malarial medicines like sulphadoxine pyrimethamine (SP) and chloroquine, which used to be first-line ant malarial medicines in Tanzania. The survey also reported that all over the country about 95% of all households possess at least one mosquito net, 9% own at least one ITN, and 90% own at least one Long Lasting Insecticidal Nets (LLIN). It also explain that 78% of children under age 5 national wide sleep under a mosquito net, 72% sleep under an ITN, and 70% slept under an LLIN. But cautiously the survey noted that ITN utilization among children tends to decrease slightly with age (THMIS 2011/12).

1.3 Malaria Epidemiology in Tanzania

Tanzania has three malaria epidemiological strata, these are:
(i) Unstable, seasonal malaria: In about 20% of the country, largely in the arid central plateau, malaria is unstable and seasonal.
(ii) Stable malaria with seasonal variations: The southern part of the country has a single main rainy season (March-May), while northern and western Tanzania experience bimodal rainfall (November-January and March-May).Seasonal malaria peaks occur at the end of the rainy season.
(iii) Perennial malaria: In the coastal fringe, southern lowlands, and regions bordering lake Victoria, malaria transmission is stable with very high transmission intensities (RBM,2012).

In areas of constant and high malaria transmission, partial immunity develops within the first two years of life. Many people, including children, may have malaria parasites in their blood without showing any outward signs of infection. Such asymptomatic infection not only contributes to further transmission of malaria but also take a charge on the health of individuals by contributing to anaemia. In the year 2006 the prevalence of malaria in Tanzania mainland was 21 percent while in the year 2008 the prevalence declined to 18 percent (THMIS, 2007/08).

The current overall prevalence of malaria in Tanzania is 9 percent with regional variations, this dramatic decline of Malaria in Tanzania mainland from 21 percent in 2006 to 9 percent in the year 2011-2012 can be attributed due to the increase of ITN ownership from 23 percent in the year 2004- 2005 to 92 percent in the year 2011-2012 (THMIS 2011/12). However a significant decline of malaria burden has been confirmed on the islands of Zanzibar after deployment of intensive malaria interventions including ACT, ITNs and IRS ( A. et al. 2011)

The ant malaria medicine artemisinin-based combination therapy (ACT) has been promoted as a means to reduce malaria transmission due to their ability to kill both asexual blood stages of malaria parasites, which sustain infections over long periods and the immature derived sexual stages responsible for infecting mosquitoes and onward transmission. Early studies reported a temporal association between ACT introduction and reduced malaria transmission in a number of ecological settings. It is effective for treatment of uncomplicated malaria and should have substantial public health impact on morbidity and mortality, but is unlikely to reduce malaria transmission substantially in much of sub-Saharan Africa where individuals are rapidly re-infected (Khatib et al. 2012)

In the year 2005, morbidity due to malaria infection was 45.58% and its mortality was 69.59% all above five years of age in Morogoro region (Morogoro regional profile 2007). Report found in Health Information Management System (HMIS) from Regional medical officer's office morogoro by the year 2012 showed that, malaria in above five years individuals accounts for 28.2% of all reported OPD cases in Morogoro Municipal council i.e. 99,088malaria cases/351,342 all diseases (HMIS-Morogoro region 2012)

Morogoro is a holoendemic malaria transmission region with seasonal peaks (MARA/ARMA 2005). The decrease of Malaria prevalence observed in Morogoro region is not so much encouraging despite of the ongoing interventions. In the THMIS 2007-2008 the prevalence was 15.7% as compared to 13% in the THMIS 2011-2012.

Therefore, with regards of all factors and reasons above this study will focus to find out the current situation on prevalence of asymptomatic malaria infection among primary school aged children in Morogoro municipal, their hemoglobin status and other effects associated with malaria infection in this age group.


1.4 PROBLEM STATEMENT

Malaria is still a public health problem in Morogoro region affecting children, pregnant women and other community members including primary school children. School aged children are the age group most commonly infected with malaria parasites. Malaria infections in primary school children are mostly asymptomatic, and therefore not early detected and treated respectively. If not treated, these infections can result into anemia and reduce children's ability to concentrate and learn in school and also if fallen sick they may lead to school absenteeism.
In most malaria endemic countries, large numbers of plasmodium falciparum infections are asymptomatic and thus form a group of individuals which called asymptomatic carrier. These carriers add up to a reservoir of malaria parasites readily available for the transmission by Anopheles mosquitoes (Kimbi 2012; Ogutu et al. 2010a)
It has shown from various literatures that school aged children are least likely to sleep under mosquito net and thereby exposed themselves to malaria risk, but also contribute to onward malaria transmission to others in the community (Noor et al. 2009)
Malaria control efforts in Africa are intensified to young children; this resulted to exposure-dependent immunity and increases the risk of malaria transmission to school aged children and above. But little is known about the burden of malaria in African school children and evidence suggests that malaria causes up to 50% of all deaths in this age group (Brooker et al. 2008)
Malaria indicator surveys conducted in sub Saharan Africa (Tanzania inclusive) use young children and pregnant women as sample population. Thus estimates of Plasmodium infection collected from this sample population may not be optimal due to the modifying presence of maternal antibodies and sequestered parasites. Hence a cheaper and rapid complementary approach to these surveys would be the use of existing school system for school-based malaria surveys (Gitonga et al. 2010; Ashton et al. 2011).
Hence, there is a need to conduct this study in Morogoro municipal to asses the current situation of asymptomatic malaria parasitaemia among primary school children, their hemoglobin level, ITNs and ACTs usage, number of school absenteeism due to malaria and other effects associated with malaria.
1.5 RATIONALE OF THE STUDY

From various studies, it has known that School age children are the age group most commonly infected with malaria parasites. The infections are usually asymptomatic, so go undetected and thus never get treated. Moreover school age children are least likely to sleep under a mosquito net and thereby exposed themselves to malaria infections and also contribute to onward malaria transmission to others in the community. If remain untreated, these infections can result into anemia and reduce children's school attendance, cognition, learning and school performance.
Therefore this study will assess situation of the current prevalence of the asymptomatic malaria infection among primary school children within Morogoro municipal council. The study will also enable to know the hemoglobin level (especially anaemia) among primary school children. The government through Ministry of health and social welfare emphasize the use of ACTs as first line for treatment of uncomplicated malaria and the use of ITNs in the protection against mosquito bites. Thus this study will determine the availability and use of these interventions which show the capacity of reducing malaria in several African countries.
Since the enrollment of primary school children in Tanzania is now becoming high, the results from this study will help to influence the policy makers i.e. MoHSW to change the malaria surveillance sample population i.e. children under fives and pregnant women to start using school based surveillance system which seems to be cheaper and also it will help to strengthen the malaria interventions to the other age groups.

1.6 RESEARCH QUESTIONS

1. What is the current malaria infection prevalence among primary school aged children in Morogoro municipal council?
2. What is the prevalence of anaemia among primary school aged children in Morogoro municipal council?
3. What is the situation of ITNs and ACTs use among school aged children in Morogoro Municipal?
4. What is the number of school absenteeism due to malaria in Morogoro municipal?

1.7 OBJECTIVES

1.7.1 Broad Objective
To determine the current prevalence of asymptomatic malaria parasitaemia among primary school aged children in Morogoro municipal.
1.7.2 Specific Objectives
1. To determine the prevalence of malaria parasitaemia among primary school children aged 6-15 years in Morogoro municipal.
2. To determine the prevalence of anaemia among primary school aged children 6-15 years in Morogoro municipal
3. To determine the proportion of ITNs use for malaria prevention among primary school children aged 6-15 years in Morogoro municipal council.
4. To determine the proportion of ACTs use for malaria treatment among primary school children aged 6-15 years with the history of malaria for the past 3-6months in Morogoro municipal.
5. To determine the proportion of self reported school absenteeism among primary school children aged 6-15 years with malaria history for the past 6 months in Morogoro municipal.
6. To determine the association between asymptomatic malaria and socio-demographic characteristics of the primary school aged children in Morogoro municipal.
7. To determine the relationship between ITNs use and malaria prevention among primary school aged children in Morogoro municipal.

1.8 CONCEPTUAL FRAMEWORK

CHAPTER TWO
2.0 LITERATURE REVIEW.

Malaria is a mosquito borne communicable disease caused by a blood protozoan parasite of the genus plasmodium and transmitted to humans by a bite of infected female anopheles mosquitoes. There are five species of parasites of the genus Plasmodium that affect humans; these are Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae and Plasmodium knowlesi). Malaria due to Plasmodium falciparum is the most deadly form and it predominates in Africa. Globally, an estimated 3.3 billion people were at risk of malaria in 2011, with populations living in sub-Saharan Africa having the highest risk of acquiring malaria: approximately 80% of cases and 90% of deaths are estimated occur in the WHO African Region, with children under five years of age and pregnant women most severely affected (WHO2012).
The risk of malaria attacks in residents of malaria endemic areas falls as they become older, suggesting that protection is a function of age (Mayor et al. 2007).
In malaria-endemic countries, a large proportion of P. falciparum infections are asymptomatic, and asymptomatic carriers do not usually seek treatment for their infection and therefore, constitute a reservoir of parasites available for transmission by Anopheles mosquitoes. It is thought that long term asymptomatic carriage may represent a form of tolerance to the parasite in children, building up their immune response, thereby protecting the children from developing either a mild malarial attack or a more severe one, by keeping their immunity effective. On the other hand, asymptomatic carriage may represent a mode of entry to symptomatic malaria, as well as transmission, especially in young children (Kimbi 2012)
In Tanzania, Plasmodium falciparum is the most common parasite. It causes severe malaria, and is fatal if not recognized promptly and properly managed. The most severe cases occur among persons who have not yet developed sufficient immunity to malaria through previous exposure (TDHS2010)
In recent years malaria parasites have developed resistance to the most commonly used ant malarial drugs in Tanzania, posing a major challenge for its control. This has led to frequent changes of malaria treatment guidelines, more recently to expensive, yet more effective arthemether/lumefantrine (ALU). The use of insecticide treated mosquito nets (ITNs) and long lasting nets (LLINs) in Tanzania has increased slowly over the past few years (NIMR final report 2008)
The use of ant malarial drug treatment (particularly ACTs), in combination with insecticide treated nets (ITNs), long lasting insecticidal nets (LLINs), and indoor residual spraying (IRS) is perhaps the most aggressive method for reducing the malaria burden in endemic regions. One study using ACT in combination with ITNs/LLINs and IRS demonstrated a 76% reduction in slide positivity for all age groups (Laishram et al. 2012)
In addition to that accurate diagnosis of malaria is critical to administering appropriate treatment. In the past, due to the high prevalence of malaria among febrile patients and the availability of cheap anti-malarial drugs, malaria was diagnosed on the basis of clinical symptoms, with only a small proportion of cases confirmed with laboratory tests. However, the World Health Organization (WHO) updated malaria treatment guidelines in 2010 to emphasize parasitological confirmation of all suspected cases. This decision was made for multiple reasons, including recent reductions in the incidence of malaria in many endemic countries, the spread of parasite resistance requiring a switch to more expensive artemisinin based combination therapy and the need to reduce drug pressure to prevent development and spread of its resistance (Aidoo et al. 2012) .
Malaria is a public health problem in Morogoro region affecting children and pregnant women. Recent findings shows slight decline of malaria prevalence in the region from 15.7% (THMIS 2007-2008) to13.7% (THMIS 2011-2012); this is equivalent to 17.2% decrease low as compared to 50% national wide decrease (18% in 2007-2008 to 9% in 2011-2012 surveillance).
2.1 Asymptomatic carriage of Plasmodium Falciparum

According to a study titled 'Declining malaria parasite prevalence and trends of asymptomatic parasitaemia in a seasonal transmission setting in north-western Burkina Faso between 2000 and 2009'2012'; they defined Asymptomatic malaria as axillary body temperature <37.5??C at presentation (and no history of fever) with microscopically confirmed Plasmodium infection (Geiger et al. 2013).
Few studies conducted in Tanzania showed the existence of plasmodium falciparum parasites in asymptomatic primary school children. Example is the study conducted in Nyamatongo ward northwest of Tanzania on the co-infections with plasmodium falciparum, schistosoma mansoni and intestinal helminthes among among 400 school children came out with the prevalence of 14.3%. Among those detected positive with malaria parasite the highest affected age group was 11-13 years school children (Mazigo et al. 2010)
In malaria-endemic countries, a large proportion of Plasmodium falciparum infections are asymptomatic or sub-clinical. Microscopy-detected levels of asymptomatic carriage as high as 39% have been reported. Invariably, this hidden pool of parasites is essential for maintaining the cycle of infection. Asymptomatic carriers do not seek treatment for their infection and, therefore, constitute a reservoir of parasites available for transmission by mosquitoes. Even in areas of highly seasonal malaria transmission, where the incidence of clinical malaria is significantly lower during the dry season, studies have shown that a considerable proportion of the population remain positive for parasitaemia throughout the year .Indeed, these reports might underestimate the level of asymptomatic carriage during the dry season, as gametocytes have been detected in prolonged sub-microscopic infections. Interestingly the prevalence of asymptomatic carriage has been reported to be greatest in adolescents and children. For example a study conducted in Gambia, showed the highest prevalence of asexual parasitaemia (61%) on individuals aged 5-15 years (Ogutu et al. 2010b; Kimbi 2012)
Parasitic disease, particularly Plasmodium falciparum malaria, remains a major health problem for schoolchildren in sub-Saharan Africa .In this population, malaria is an important contributor to anemia, malnutrition, and mortality. In addition, impaired cognition and poor school performance are important hidden burdens of malaria, which may prevent children from achieving their full educational potential. In a study to investigated the association between asymptomatic Plasmodium infection and cognitive function among schoolchildren in eastern Uganda, where malaria transmission is perennial and high; predominantly caused by Plasmodium falciparum and Anopheles gambiae , and to a lesser extent, Anopheles funestus are the main vectors , and also asymptomatic Plasmodium infections are common; the results from this study showed that asymptomatic Plasmodium infections are strongly associated with poor performance in tests of abstract reasoning and sustained attention. In this study parasitaemia measured by thick blood smears, were present in 30% of the children (Nankabirwa et al. 2013)
However children under the age of five years and pregnant women are the primary targets for most malaria control programs. These populations experience the most acute symptoms of malaria, and cases are more likely to result in mortality. However, school age children are the age group most commonly infected with malaria parasites. These infections are usually asymptomatic, so go undetected and thus never get treated. School age children are also least likely to sleep under a mosquito net and thereby are not only themselves the most exposed to malaria risk, but also contribute to onward malaria transmission to others in the community (Noor et al. 2009). If untreated, these infections can result in anemia and reduce children's ability to concentrate and learn in school (Clarke et al. 2008)
Another study conducted in Kenya to assess the overall prevalence of asymptomatic Plasmodium falciparum parasitaemia by age revealed that; the prevalence of infection detected in pooled blood samples by microscopy and/or PCR analysis was similar among subjects aged 5'9 years (34.4%) and those aged 10'14 years (34.1%).On the other hand, the prevalence among pooled blood samples from children aged 14 years (9.1%) was significantly less than that among pooled samples from younger children (Baliraine et al. 2009)
The pathogenesis of malaria is complex, and the clinical presentation of disease ranges from severe and complicated, to mild and uncomplicated, to asymptomatic malaria. Despite a wealth of studies on the clinical severity of disease, asymptomatic malaria infections are still poorly understood. Asymptomatic malaria remains a challenge for malaria control programs as it significantly influences transmission dynamics. It is not clear why some Plasmodium falciparum infections are symptomatic while others are asymptomatic, but parasite factors are likely to be involved. Malaria parasites influence disease outcome through factors that include parasite density, rosetting and sequestration, toxin production, and genetic diversity including expression of virulence and immune evasion genes such as the var (variant antigen receptor) gene family. Intermittent preventive treatment (IPT), the administration of a full course of an anti-malarial treatment to a population at risk at specified time points regardless of the infection status of individuals, has been proposed as a method of treatment for asymptomatic individuals to reduce transmission of disease. Artemether-lumefantrine (ALU), an ACT drug currently available on the market, has been suggested as a candidate for IPT treatment of asymptomatic carriers (Laishram et al. 2012)
It is also noted that, People living in areas where malaria transmission is low and unstable remain at risk of clinical attacks of malaria at older ages, and epidemics can result in increased morbidity among school children, more deaths, and considerable disruption of schoolwork (Clarke et al. 2004).

2.2 Insecticide Treated Nets

An insecticide-treated net is a mosquito net that repels disables and/or kills mosquitoes coming into contact with insecticide on the netting material. There are two categories of ITNs: conventionally treated nets and long-lasting insecticidal nets:
(i) A conventionally treated net is a mosquito net that has been treated by dipping in a WHO-recommended insecticide. To ensure its continued insecticidal effect, the net should be re treated after three washes, or at least once a year.
(ii) A long-lasting insecticidal net(LLIN) is a factory-treated mosquito net made with netting material that has insecticide incorporated within or bound around the fibers. The net must retain its effective biological activity without re-treatment for at least 20 WHO standard washes under laboratory conditions and three years of recommended use under field conditions: They have the following mode of actions; act as a physical barrier, preventing access by vector mosquitoes and thus providing personal protection against malaria to the individual(s) using the nets. Pyrethroid insecticides, which are used to treat nets, have an excito-repellent effect that adds a chemical barrier to the physical one, further reducing human'vector contact and increasing the protective efficacy of the mosquito nets. Most commonly, the insecticide kills the malaria vectors that come into contact with the ITN. By reducing the vector population in this way, ITNs, when used by a majority of the target population, provide protection for all people in the community, including those who do not themselves sleep under nets (WHO/GMP 2007).

Studies revealed that insecticide-treated mosquito nets (ITNs) used for protection against mosquito bites has proven to be a practical, highly effective, and cost-effective intervention against malaria. The evidence of the public health impact of ITNs, supporting their wide-scale use in Africa, is drawn from areas of stable malaria transmission where Plasmodium falciparum infection prevalence in the community is often over 40%. Community-based randomized controlled trials (RCT) in these regions have documented average reductions of 20% in all causes of mortality in children under 5 years old within 2 years of increasing ITN use from 0 to 50-70%. Scaling up ITN coverage and use by young children and pregnant women has been made a consensus target of the Millennium Development Goals (MDGs), the Roll Back Malaria Partnership (RBM), and the US President's Malaria Initiative (PMI). Targeting individual protection to these vulnerable groups is a well-founded and explicitly accepted priority of all three initiatives because these groups bear the highest risk of morbidity and mortality from malaria. However, this strategy ignores the potentially greater community-wide benefits of broader population coverage in areas of moderate and seasonal transmissions, like the highlands, where all age groups are equally vulnerable and no explicit resources, targets, or strategies have been proposed to achieve protection. But a study in Kenya revealed that usage of ITNs in young children below age of 5 years with nets was often as high as or higher than for adults above 15 years old. Children between ages of 5-14 years had significantly lower usage during the dry and rainy seasons. This phenomenon has also been found elsewhere in studies in Uganda, Ghana and the Gambia (Atieli et al. 2011)
Other study conducted in eastern Ethiopia showed that; women's and head of household's education, head of household's occupation, marital status, household size, household wealth, living in rural areas, and expenditure on other malaria prevention products and practices were found to be associated with ITN ownership. A strong association remained between using ITNs, owning a radio, and living close to a health institution. In addition, households' desire for mosquito avoidance and correct knowledge of malaria transmission is shown to be strong determinants of ITN usage (Biadgilign et al. 2012).
There is growing evidence documenting a substantial decline in clinical malaria morbidity and mortality in a number of African Countries. This can be attributed to malaria control measures, predominantly to the use of insecticide treated nets (ITNs) indoor residual spray (IRS) and artemisinin-based combination therapies (ACT), which have been implemented on a wide scale (Zhou et al. 2011).
Across 36 African countries, ITNs scale-up is estimated to have reduced malaria mortality deaths by 24% in year 2010, and to have prevented 842,800 under-five deaths between 2001 and 2010 (Korenromp 2012)

2.3 Artemisinin based Combination Therapies.

These are combinations in which one of the components is artemisinin and its derivatives (artesunate, artemether, dihydroartemisinin). The artemisinins produce rapid clearance of parasitaemia and rapid resolution of symptoms, by reducing parasite numbers 100- to 1000-fold per asexual cycle of the parasite (a factor of approximately 10 000 in each 48-h asexual cycle), which is more than the other currently available antimalarials achieve. Artemisinin-based combination therapies (ACTs) are the recommended treatments for uncomplicated Plasmodium falciparum malaria. The following ACTs are recommended: artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, and artesunate plus sulfadoxine-pyrimethamine (WHO2010).
The steady increase of drug resistant malaria across Africa is a crisis for which there are achievable solutions, but not easy ones. The scale of the problem is not in doubt. In Africa malaria remains one of the commonest causes of death and serious morbidity, especially for children and pregnant women. Despite a decision in principle by many countries in Africa to use artemisinin based combination therapies (ACTs), most cases of malaria are still treated with monotherapy and in many areas most of these treatments will fail. Drug combinations, rather than monotherapy, are now seen to be the best solution for treating malaria, and artemisinin based drug combinations are highly effective, with cure rates similar to that of chloroquine 30 years ago. They seem to be a good long term choice for most African countries, being safe and well tolerated (with the caution that their safety in early pregnancy is not yet clear). In areas of relatively low malaria transmission in South East Asia and South Africa, widespread use of ACTs has reduced significantly the burden of malaria. This benefit is likely being less marked in areas of very high transmission in Africa, where much of the reservoir of malaria infection is in asymptomatic people who never seek treatment (Malenga et al. 2005)
Furthermore, Artemisinin-based combination therapy (ACT) has been promoted as a means to reduce malaria transmission due to their ability to kill both asexual blood stages of malaria parasites, which sustain infections over long periods and the immature derived sexual stages responsible for infecting mosquitoes and onward transmission. Early studies reported a temporal association between ACT introduction and reduced malaria transmission in a number of ecological settings. An observational study in Tanzania shows that the introduction of ACT at fixed health facilities only modestly reduced asexual parasitaemia prevalence. ACT is effective for treatment of uncomplicated malaria and should have substantial public health impact on morbidity and mortality, but is unlikely to reduce malaria transmission substantially in much of sub-Saharan Africa where individuals are rapidly re-infected (Khatib et al. 2012; Ogutu et al. 2010a)
To assess the achievements of malaria control interventions, monitoring and evaluation is always conducted using community surveys. Malaria endemic countries in Sub Saharan Africa(Tanzania inclusive) has been mainly based on periodic national household surveys, including malaria indicator survey(MIS) as well as malaria modules of demographic health surveys(DHS) and multiple indicator cluster surveys, where young children and pregnant women form the sample population. However, household surveys are expensive, time consuming and labour intensive, and generally only undertaken every 3-5 years and therefore not ideal for routine monitoring at local levels. Furthermore, estimates of Plasmodium infection collected among young children and pregnant may not be optimal due to the modifying presence of maternal antibodies and sequestered parasites. A cheaper and rapid complementary approach to household surveys would be to use the existing school system for school-based malaria surveys(Gitonga et al. 2010; Ashton et al. 2011)

CHAPTER THREE
3.0 METHODOLOGY
3.1 Study Design
This will be a descriptive Cross-sectional study used to determine the current malaria prevalence on asymptomatic primary school aged children in Morogoro municipal.
3.2 Description of the Study Area.
This study will be conducted Morogoro Municipal council which is within Morogoro region that has an altitude of 500-600m above sea level and which is also located between longitude 37??-39??E and latitude 6??-5?? S. The Municipal consists of the town of Morogoro, one of oldest towns in Tanzania. This town is located about 223 kilometers south east of the capital city Dodoma and 195 kilometers west from the commercial city of Dar es Salaam, it has a population of 315,866 (tnbs2012 census). It is a capital of the Morogoro region and enjoys a mixture of warm and cool temperature ranging between 27??C to 33.7??C in the dry/warm season and 14.2??C to 21.7??C in cold/wet season.
The Municipality experiences a sub-humid tropical climate with a bimodal rainfall pattern characterized by two rainfall seasons in a year with a dry season separating the short rains (October to December) and long rains (which fall from March to May/June).
Municipal borders Mvomero District in the north, west, and south and Morogoro District'Rural in the east. The municipality is also the regional capital for Morogoro Region. Morogoro Municipality is 260 square kilometers, major geographical features include the famous Uluguru Mountains, which lie in the south-eastern part, and Mindu mountains, which lie in the western part.
For administrative purpose the municipal has only one administrative division with nineteen wards namely ; Bigwa, Boma , Kichangani, Kihonda, Kilakala, Kingo, Kingolwira, Mafiga, Mazimbu, Mbuyuni, Mji Kuu, Mji Mpya, Mlimani, Mwembesongo, Mzinga, Sabasaba, Sultan Area, Uwanja wa Ndege, Uwanja wa Taifa.
In health services, malaria is a leading cause of morbidity and mortality among the top ten diseases and conditions. Other diseases and conditions are Pneumonia, Diarrhorea ,Anaemia, Protein Calorie Malnutrition (PCM) ,Tuberculosis (TB) , Poisoning , Acute Respiratory Infection (ARI), Cardiac Failure (CF) ,Diabetes ,HIV/AIDS, Epilepsy , Hypertension, Asthma ,Worms ,Poisoning ,Burn (Morogoro Regional Profiles2007). There are 46 health facilities both private and government owned within the municipality (MoHSW2013).
Furthermore in primary education services, the municipal council owns and operates sixty (60) primary schools. Each ward within the municipal has at least one primary school (Morogoro Regional Profiles2007)
The decrease of malaria prevalence in the whole region is not encouraging despite of the several malaria interventions taking place. The decline from 15.7% to 13% malaria prevalence is to minimal as compared to the nationwide decline i.e. from 18% to 9%. Furthermore Malaria is also a leading cause of OPD attendance for above 5years patients in all councils within the region. (HMIS-Morogoro region 2012)

3.3 Study Population
The study will involve all primary school children aged 6-15years in Morogoro municipal council from which blood samples will be taken for malaria parasites and haemoglobin level examinations, then students will be interviewed on the use of Insecticide Treated Nets and and Artemisinin based Combination Therapies.
3.4 Study Unit
The study will be carried out from 5 primary schools out of 60 public primary schools within the Municipal. The sample size of the participant school children will be obtained from the randomly selected 5 primary schools.

3.5 Eligibility
Inclusion criteria.
i. All asymptomatic primary school children aged 6-15years from standard two up to standard six who will agree to participate in the study
ii. School children with signed informed consent from their parents or care takers.
iii. Those who will attend school on a day when data collection will be taking place.

Exclusion criteria.
i. Primary School children who will be unwilling to participate in the study
ii. Primary school child who is Known or suspected to have sickle cell disease

3.6 Sample Size
The minimum sample size for this study will be obtained from the following formula.

n=z?? P (100-P)
'?

Where;
n: Desired minimal sample size.

Z: Confidence interval level at 95% i.e. (1.96)

P: Proportion of the primary school children asymptomatic for malaria infection; which is 32.2%. This proportion is based from the average of two studies conducted in neighboring east African countries .The study by Nankabirwa et al (2013) show, the proportion of asymptomatic malaria in primary school children in Uganda was 30%, while study in Kenya by Baliraine et al, (2009) show the prevalence of asymptomatic malaria in school children was 34.1%.
??:Margin of error on the proportion (p) which is set to be 5%
Hence, n= 1.96?? x 32.2 (100-32.2)
5??
n = 333
Adding 5% of dropout and non respondent's students (17), therefore 350 participants will be recruited in the study.

3.7 Sampling Techniques
In this study, a random cluster sampling will be used to obtain the required primary schools while simple random sampling technique will be used to obtain participant students as a representative sample size.
Thus from the list of all primary schools within Morogoro municipal council, 5 primary schools will be selected using a random cluster sampling, then from each randomly selected school, a simple random sampling technique will be used to recruit 70 primary school students from a list of all school children from standard 3 to standard 7 who will be available on the sampling day. The eligible students will be mobilized in one classroom, then brief explanation of the study will be given to them, after that student will be argued to pick one folded paper which will be written either 'Included' or 'Not Included'. Thus those school children who will pick a folded paper which written Included will be recruited in the study.
Therefore the selected children will be given a written Informed consent form for their parents or guardians to read and sign if they will agree their children to participate in the study. For those parents who cannot read, the children will be instructed to read for them.

3.8 Research Assistants and Pilot Study
Four research assistants with medical background will be recruited and oriented in the study; these will be two medical laboratory technicians and two medical laboratory assistants. The questionnaires will be pre-tested in one of the primary school to countercheck for the questions if will be understood, if the sequence of questions is logical and if there will be need of modification or rephrasing them. The school which will be used as pilot study will be excluded in the study during data collection.

3.9 Data collection Techniques

A structured and pre-tested questionnaire will be used to collect information on socio-demographic factors, knowledge about the transmission and prevention of malaria, ownership and utilization of ITNs plus use of ACTs in the past 6 months to all 350 eligible participants. The interview will be conducted in Swahili language.
3.10 Parasitological Examination.

Presence of malaria parasites among asymptomatic school children will be ascertained during this study surveys by using multi-species malaria rapid diagnostic test (mRDT) with the aid of trained laboratory technician.
3.10.1 Quality Control
Microscopy quality control will be conducted whereby thick blood films will be fixed and stained at Morogoro regional referral hospital after the survey, and will be examined after completion of field work by experienced laboratory technician in Morogoro. A second reading will be carried out by highly experienced technician at MUHAS parasitology laboratory and then results will be compared.
3.11 Haemoglobin Measurements.
Hemoglobin level will be measured at the field using portable Easy Touch?? GHb system machine by examining peripheral blood from finger pricks. Definition of anemia will be based on WHO criteria and national guidelines definition where hemoglobin level is < 7g/dl is regarded as severe anemia, hemoglobin level between 7-9.9g/dl is moderate anemia, hemoglobin level between 10-10.9g/dl is mild while hemoglobin level of ' 11g/dl is regarded as normal hemoglobin level (WHO, 2011).

3.12 Study Variables
3.12.1 Dependent Variables
1. Malaria parasite
2. Hemoglobin level
3. School Absenteeism
3.12.2 Independent Variables
1. ACTs use
2. ITNs use
3. Age
4. Sex
5. Class level.

3.13 Limitations of the Study.

1. Reliability of RDTs among school children malaria diagnosis. RDTs can results into false positive especially when using Histidine-rich Protein type 2 antigen type.
2. Reliability of school children's reports on ITNs ownership and use
3. School children absenteeism during the day of survey, thus not included in sample population. This may lead to unrepresentative.
4. Difference in school children enrolment from one primary school to another, thus may not provide truly representation of malaria among school aged children in Municipality.
(Gitonga et al,.2010)

3.14 Data Management and Analysis
The data entry, storage and analysis will be done by the principal investigator (PI) using SPSS version 15 software. The double entry will be done for raw data to minimize possible errors during data entry. Frequencies and cross tabulation will be calculated to obtain proportions and chi squared tests for each of the study variables. Chi-square test, bivariate (correlation analyses) and linear regression analyses will be done to obtain the association and relationship between independent and dependent variables. P value of <0.05 at 95% CI will be used to test the statistical significances between the dependent and independent variables. The results will be presented into tables and graphs.
Analyses Plan: Below is the data analyses plan on different specific objectives of this study.
Table1: Prevalence of Malaria in sex of Primary school children (Cross-tabulation; test; P value <0.05 at 95% CI).
socio-demographic characteristics Category Malaria infection
Total
Positive Negative
Sex

Male
Female
Total
Age group (in Years)


6-9
10-12
13-15
Total

NB: Again the table above will help to answer the specific objective number 6 which aimed to determine the association between asymptomatic malaria and socio-demographic characteristics of the primary school aged children in Morogoro municipal'

Table 2: Prevalence of Anemia among primary school aged children (Cross-tabulation; test; P-value <0.05 at 95% CI)
socio-demographic characteristics Category Haemoglobin level
<7g/dl Severe anaemia 7-9.9g/dl Moderate anaemia 10-10.9g/dl Mild anaemia '11g/dl Normal haemoglobin
Sex Male
Female
Total

From this specific objective, the difference in haemoglobin level (Anemic and Normal Haemoglobin) will be assessed among those who will be Malaria positive and those Malaria negative. Bivariate analysis will be used analyze the association. But it will be worth enough to make an assumption that other factors which can contribute to anaemia like intestinal worms and sickle cell disease are kept constant to all comparison groups (i.e. Malaria positive and Malaria negative)
Table 3: Proportion of ITNs use for malaria prevention among Primary school aged children (Cross-tabulation; test; P-value <0.05 at 95% CI)
socio-demographic data Category Insecticide Treated Nets (ITNs) use
Total
Yes No
Sex

Male
Female
Total
Age group (in years)


6-9
10-12
13-15
Total

Table 4: Proportion of ACTs use for malaria treatment among primary school aged children (Cross-tabulation; test; P-value <0.05 at 95% CI)
socio-demographic variable Category Types of ant malaria used
ACTs (e.g. Alu, Artequine, etc.) SP Chloroquine Others
Sex Male
Female
Total

Table 5: Proportion of self reported school absenteeism due to suspected malaria fever
School Absenteeism due to malaria
Responses Frequency Percentage
Yes
No
Total

But in addressing specific objective number 7 which entails to determine the relationship between ITNs use and malaria prevention among primary school aged children in Morogoro municipal. Thus correlation /Regression analysis will be used to see whether or not the relationship exists. If correlation analyses (Pearson correlation test will be used to examine the relationship. However if Regression analyses will be used (simple linear regression will be used to examine the relationship between ITNs use and malaria prevention among primary school aged children.). P-value <0.05 will be used to test the statistical significance of the relationship.

3.15 Ethical Consideration
Ethical clearance will be sought from Muhimbili University of Health and Allied Sciences before commencing the study. The Institution Review Board (IRB) will review this proposal and advice accordingly. The after the clearance, the permission will be requested from the District Executive Director (DED) through District Education Officer to allow the Principal Investigator to conduct this study in their school children. Then informed consent will be requested from primary school head teacher in each school after having a permission letter from District Education Officer and finally a written informed consent form will be given to the selected school children. The selected school children will be requested to bring the written informed consent to their parents or guardians and request them to read and sign if they allow their children to participate in the study. After then all selected children will be instructed to send back the signed informed consent forms. Parents/guardians who will not want their children to participate in the study will be free to refuse participation. If a parent or guardian chooses not to allow their children to participate in the survey, the child's name will be removed from the school participants list. During data collection procedures, those participants who will be diagnosed having anemia and any other health related problems will be referred to the nearest health facility for further medical management

CHAPTER FOUR
4.0 BUDGET
A total of 3,258,300/=Tshs will be required to accomplish this study. The table below show cost distribution for each item or activities.
No_ Activity Inputs Unit cost Total unit cost Total Activity cost (Tshs)
1 Stationery &Computer work
Proposal development Printing &binding 1 1 100,000 100000
Dissertation report Analysis, writing, &binding 6 1 85000 510000 610000

2 Diagnostic instruments Easy Touch?? GHb system machine 1 1 700000 700,000
Easy Touch?? Haemoglobin test strips (into pcs) 400 1 1720 688,000
Giemsa stain (in gm) 200 1 204 40,800
Blood lancets (400pcs) 1 1 7000 7,000
Malaria rapid diagnostic test (400 tests) 1 1 400000 400,000 1,835,800
3 Allowances Research assistance 5 5 32500 812,500 812,500
GRAND TOTAL 3,258,300

NB: Medical equipments, reagents and supplies are priced using Tanzania Medical Store Department (MSD) price catalogue 2012/2013.

4.1 PLAN OF ACTIVITIES

Proposal development
Proposal correction
Proposal review by panel
Data collection
Data processing
Data Analysis
Report writing
Dissertation submission
Dissertation defense
Panel comments inclusion, binding & submission
Jan Feb March April May June July August
(In the year 2014)

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Appendix- I: QUESTIONNAIRE (English version)
ID number_________________________
RESEARCH TITLE: ASYMPTOMATIC MALARIA INFECTION AMONG PRIMARY SCHOOL AGED CHILDREN IN MOROGORO MUNICIPAL, TANZANIA.
PART A: Demographic Data:
1. School name'''''''''''''''''.

2. Sex : (1) Male
(2) Female
3. Age in years of respondent''''''

4. In which Class are you now?
(1) Standard two
(2) Standard Three
(3) Standard Four
(4) Standard Five
(5) Standard Six

***PART B: Malaria and Haemoglobin: Field Investigations***
5. What is his/her malaria status?
(0) Negative
(1) Positive

6. What is his/her haemoglobin level in numbers?...........................................

PART C: Insecticides Treated Nets (ITNs):
7. Have you heard about ITNs?
(1) Yes
(2) No
If No skip to question (9); If yes proceeds to next questions
8. Where did you get information on ITNs?
(1) From Radio
(2) From Television
(3) Health Facility
(4) School
(5) Others specify''''''''''''''''''''..

9. How do you get ITNs at your home?
(1) Parents buy at shops
(2) Free of charge from malaria campaign
(3) By using National Voucher Scheme 'HATI PUNGUZO' from health facility
(4) Others specify'''''''''''''''''''''.

10. Do you sleep under ITN?
(1) Yes
(2) No
If no skip to question (13); If Yes proceeds to next questions except question (13&14)
11. When do you normally sleep under ITN?
(1) Every day at night when sleeping
(2) When fallen sick
(3) Some few days

12. Did you sleep under ITN last night?
(1) Yes
(2) No

13. Why don't you sleep under ITN?
(1) I do not have ITN
(2) I am not feeling comfortable to sleep under ITN
(3) Not important
(4) Others specify''''''''''''''''''''''.

14. Why don't you have ITN?
(1) It is expensive
(2) It is not important
(3) Others specify''''''''''''''''''''''.
15. What are the other uses of ITNs in your home?
(1) Chicken protection against predators
(2) Garden fencing to protect vegetables
(3) Others specify'''''''''''''''''''''''.

16. Do you think sleeping under ITNs can cause any negative effect on your health?
(1) Yes
(2) No

If No skip to part D

17. What are the negative effects do you think caused by the use of ITNs?
(1) Feeling like suffocating
(2) Cause skin rashes
(3) Causes impotence
(4) Feeling hot when a sleep
(5) Others specify'''''''''''''''''''''..

PART D: Artemisinin based combination therapy (ACTs) use:
18. Have you heard about ACTs?
(1) Yes
(2) No
If No skip to question (20)
19. What do you know about ACTs?
(1) First line drug for treatment of uncomplicated malaria
(2) Drug used for the treatment of diarrhea
(3) Drug used for the treatment of pneumonia
(4) Others specify'''''''''''''''''
20. Do you remember if you had suffered from malaria?
(1) Yes
(2) No
If YES continue to next questions, If NO stop here.
21. When did you suffered from malaria?
(a) This month
(b) Two months ago
(c) Three months ago
(d) Four months ago
(e) Six months ago

22. When you suffered from malaria, which drug do you take normally?
(1) ACTs
(2) Chloroquine
(3) Sulphadoxine/Pyrimethamine (SP)
(4) Quinine
(5) Others specify'''''''''''

23. When you fallen sick suspected to malaria, what do you do before starting treatment?
(1) My parents send me to hospital for diagnosis and prescription
(2) My parents buy malaria drugs for me from nearby without prescription pharmacy
(3) Wait until condition is worse
(4) Others specify'''''''''''''''''''..

PART E: Self reported school Absenteeism
24. Did you miss classes due to malaria suspected fever?
(1) Yes
(2) No
*******************************************************************************

Appendix II: QUESTIONNAIRE (Swahili version)
Namba ya Dodoso___________________________________
DODOSO KUHUSU: KIWANGO CHA MAAMBUKIZI YA UGONJWA WA MALARIA KWA WANAFUNZI WA SHULE ZA MSINGI MANISPAA YA MOROGORO.

SEHEMU A: Taarifa za Kidemografia:
1. Jina la shule''''''''''''''''
2. Jinsia:
(1). Mwanaume
(2) Mwanamke
3. Umri wa mwanafunzi''''''.
4. Uko darasa la ngapi?
(1) Pili (2) Tatu (3) Nne
(4) Tano (5) Sita

*******SEHEMU B: Matokeo ya Upimaji wa Malaria na Uwingi wa Damu.*****
5. Je ana maambukizi ya Malaria?
(0) Hapana
(1) Ndiyo
6. Kiwango cha Uwingi wa damu'''''''''.

SEHEMU C: Matumizi ya Vyandarua Vyenye Dawa
7. Je, umewahi kusikia kuhusu vyandarua vyenye dawa ya kuua mbu?
(1) Ndiyo
(2) Hapana

Kama jibu ni HAPANA nenda swali la (9), kama jibu ni NDIYO endelea na maswali yanayofuata.
8. Ulipata wapi taarifa kuhusu vyandarua vyenye dawa?
(1) Redio
(2) Runinga (Televisheni)
(3) Kituo cha Afya
(4) Mengineyo (taja)'''''''''''''''''''..

9. Huwa mnapataje vyandarua vyenye dawa nyumbani kwenu?
(1) Wazazi hununua dukani
(2)Kupewa bure kutokana na kampeni za ugawaji vyandarua
(3)Kutumia HATIPUNGUZO kutoka kituo cha Afya
(4) Mengoneyo (taja)'''''''''.
10. Unatumia chandarua chenye dawa wakati wa kulala?
(1) Ndiyo
(2) Hapana.

Kama jibu ni Hapana nenda swali la (13), Kama jibu ni Ndiyo endelea maswali yanayofuata kasoro swali la (13 na 14)
11. Ni mara ngapi huwa unatumia chandarua chenye dawa?
(1) Kila siku usiku wakati wa kulala
(2) Nikiwa naumwa
(3) Mara chache chache

12. Umetumia chandarua chenye dawa wakati wa kulala usiku wa kuamkia leo?
(1) Ndiyo
(2) Hapana

13. Kwanini hutumii chandarua chenye dawa wakati wa kulala?
(1) Sina chandarua chenye dawa nyumbani
(2) Sijisikii vizuri nikitumia chandarua chenye dawa
(3) Havina umuhimu kuwa navyo
(4) Mengineyo (taja)'''''''''''''''''''

14. Kwanini huna chandarua chenye dawa?
(1) Vinauzwa bei kubwa sana
(2) Siyo muhumu kuwa navyo
(3)Mengineyo (taja)''''''''''''''.

15. Nini matumizi mengine ya vyandarua nyumbani kwenu?
(1) Kukinga vifaranga dhidi ya wanyama wakali
(2) Kuweka uwigo bustani kukinga mboga
(3) Mengineyo (taja)'''''''''.

16. Unafikiri kuna madhara yoyote ya kiafya ukilala kwenye chandarua chenye dawa?
(1) Ndiyo
(2) Hapana
Kama jibu ni Hapana nenda Sehemu D
17. Je ni madhara gani unahisi unaweza kupata ukilala kwenye chandarua chenye dawa?
(1) Unahisi kushindwa kupumua vizuri
(2) Utapata vipele kwenye ngozi
(3) Hupunguza nguvu za kiume
(4) Huleta joto sana wakati wa kulala
(5) Mengineyo (taja)''''''''''''''''''''''.

SEHEMU D: Matumizi ya Dawa Mseto
18. Umesha wahi kusikia kuhusu dawa mseto ya malaria?
(1) Ndiyo
(2) Hapana.
Kama jibu ni Hapana, nenda swali (20)
19. Unajuwa nini kuhusu dawa mseto
(1) Dawa ya kwanza kutibu malaria isiyo kali
(2) Dawa ya kutibu kuharisha
(3) Dawa ya kutibu homa ya kifua 'Kichomi'
(4) Mengineyo (taja)''''''''''''''''''''

20. Je unakumbuka kama umeshawahi kuugua Malaria?
(1) Ndiyo
(2) Hapana
Kama jibu ni NDIYO endelea maswali yanayofuata, Kama jibu ni HAPANA ishia hapa.

21. Lini uliugua malaria.
(1) Mwezi huu
(2) Miezi miwili iliyopita
(3) Miezi mitatu iliyopita
(4) Miezi mine iliyopita
(5) Miezi sita iliyopita.
22. Ukiugua malaria ni dawa gani unaitumia kwa matibabu?
(1) Mseto
(2) Chloroquine
(3) SP
(4) Quinine
(5) Zingine (taja)'''''''''''

23. Unapohisi kuugua malaria, ni kitu gani cha kwanza hufanya kabla ya kuanza matibabu?
(1) Wazazi/Walezi hukupeleka hospitali kufanyiwa vipimo na kupewa dawa
(2) Wazazi/Walezi huninunulia tu dawa yam alia kwenye duka jirani la Dawa
(3) Nasubiri mpaka hali inapokuwa mbaya
(4) Mengineyo (taja)''''''''''''.

SEHEMU E: Taarifa binafsi ya kutohudhuria shuleni.

24. Umeshawahi kukosa vipindi/kutokuja shule kwa kuumwa homa unayo hisi ni malaria?
(1) Ndiyo
(2) Hapana

****************************************************************

Appendix III: Field Laboratory Investigation Form.

Form number__________________ (Should be the same as with Questionnaire number)

Finger pricks blood sample results:
1. Malaria parasites with mRDT
1. Positive
2. Negative
2. Malaria parasite blood smears with Microscopy
1. Positive
2. Negative
3. Parasites count (Parasites/200WBC) _____________________________
4. Haemoglobin level (g/dl)
Write exact number as reading from the machine: _____________________________

Source: Essay UK - http://www.essay.uk.com/free-essays/science/tropical-diseases-control.php



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