I^KIHO.S G2 Q2 bite C.l G371185 3 0 692 1 000 6958 O University of Ghana http://ugspace.ug.edu.gh CHILDHOOD FEBRILE ILLNESS, ARE WE OVER DIAGNOSING MALARIA? This dissertation is submitted to the School o f Public Health, University o f Ghana, Legon, in partial fulfillment o f the requirement fo r the award o f Master o f Public Health Degree. PRESENTED BY ALBERTA AMU QUARTEY SPH, MPH 2002/3 AUGUST 2003 University of Ghana http://ugspace.ug.edu.gh Academic Supervisors 1. Dr. Matilda Pappoe School of Public Health University of Ghana, Legon. 2. Dr. Irene Agyepong Amartefio District Director of Health Services Dangme West District. University of Ghana http://ugspace.ug.edu.gh Declaration I declare that this study has been the result o f my own research conducted under supervision, and has not been presented for a degree in any other University or Institution ^ ( O M m - ...................................................................................... Designation MPH Resident Date: / V 1 2 . ( a x r o s Signed... Designation Date: Academic Supervisor Signed........................... Designation Academic Supervisor Date: ii University of Ghana http://ugspace.ug.edu.gh Acknowledgement My gratitude goes to the Director, Lecturers and sta ff o f the School o f Public Health. I wish to acknowledge the guidance and support o f Dr. Matilda Pappoe, my academic supervisor, Drs Irene Agyepong Amartefio and Evelyn Ansah, my fie ld supervisors. Many thanks also go to the Head and sta ff o f the Dodowa Health Center who made me feel at home and helped with the data collection. I also wish to thank the caregivers and the children who allowed us to enroll them into the study University of Ghana http://ugspace.ug.edu.gh Dedication This work is dedicated to the children who took part in this study. University of Ghana http://ugspace.ug.edu.gh Supervisors.....................................................................................................................................1 Declaration.....................................................................................................................................11 Acknowledgement...................................................................................................................... 111 Dedication.................................................................................................................................... 1V Table of Contents...........................................................................................................................v List of Tables and Diagrams......................................................................................................vii List of Acronyms.................................................................................................................................. viii Abstract.......................................................................................................................................... ix Chapter One Introduction.............................................................................................................................. 1 1.1 Background......................................................................................................... 1 1.2 Rationale for Study........................................................................................... 2 1.3 Purpose of study................................................................................................4 Chapter Two Literature Review.....................................................................................................................5 2.1 Malaria and Bacterial Infections....................................................... 5 2.2 Some Immunological aspects of malaria..........................................7 2.3 M alaria...............................................................................................................7 Table of Contents University of Ghana http://ugspace.ug.edu.gh Chapter Three Study Protocol..........................................................................................................................10 3.1 Study Obj ecti ves.................................................................................................10 3.2 Definition of Malaria......................................................................................... 10 3.3 Study Site............................................................................................................ 11 3.4 Study Design.......................................................................................................12 3.5 Laboratory Evaluations......................................................................................14 3.6 Data Management and Statistical Analysis........................................................ 15 3.7 Limitations..............................................................................................................16 Chapter Four Results..........................................................................................................................................18 Chapter Five Discussion................................................................................................................................... 23 Chapter Six Conclusion and Recommendations..........................................................................................25 REFERENCES.......................................................................................................................... 26 APPENDICES: 1. Consent Form.................................................................................................................a 2. Blood Smear Results Form.......................................................................................... d 3. Questionnaire................................................................................................................. e 4. Physical Examination Report Form..............................................................................j University of Ghana http://ugspace.ug.edu.gh Lists o f Tables and Diagrams List of Tables Table 1— Sex of participants Table 2—Occupation of caregivers Table 3—Distribution of formal education levels attained by Primary Caregivers Table 3 —Blood culture results List of Diagrams Figure 1— Age group distribution of participants Figure 2 — Distribution of mean parasite densities (count/ul) by age University of Ghana http://ugspace.ug.edu.gh HPF High Power Field IMCI------------ Integrated Management of Childhood Illness RBM ----------Roll Back Malaria ul---------microliter UNICEF United Nations Children’s Fund wbc------white blood cells WHO World Health Organization List of Acronyms University of Ghana http://ugspace.ug.edu.gh Abstract Malaria and bacterial infections are major causes of febrile illness in the developing world. To investigate the contribution of malaria and concurrent bacterial infection to febrile illness in children, 50 children aged 6 to 60 months, who presented with fever 37.5 C (axillary) or above at the Dodowa Health Center, a primary care center between July and August (wet season) 2003 were enrolled into a study. The most common presenting signs were vomiting (54%), inability to suck or eat (56%) liver enlargement (48%) and pale conjunctivae (48%). The mean axillary temperature recorded was 38.53 C (SD 2.889). The highest recorded temperature was 40 C (in 8% of cases). Ninety-six percent (96%)of participants had positive blood smears for malaria parasites, but only 28 % had parasite densities above 2500/ul (clinical malaria). All positive smears had plasmodium falciparum species. The mean parasite density was 3541.74 counts per ul (minimum and maximum parasite densities were 80 and 28,800 counts per ul respectively). Of those who had presenting axillary temperature 40 C or above (N=4), two had no bacterial growth; one had mixed bacterial growth (of acute phase blood culture), which was more probably due to contamination of the sample with skin flora, whiles one had positive streptococcal spp growth. Sixty percent (60%) of the children had been given some sort of treatment before presentation, Thirty percent (30%) were given antimalarial (chloroquine) but only 15% receive adequate doses. Two percent were given antibiotics University of Ghana http://ugspace.ug.edu.gh It is recommended that caregiver education on the prevention and proper management of fever be intensified. There is also the need for more research into malaria and concurrent bacterial infection. University of Ghana http://ugspace.ug.edu.gh Chapter One 1.0 Introduction 1.1 Background Malaria and Infectious diseases remain the leading causes o f morbidity and mortality in sub-Saharan Africa where malaria alone represents 9% of the continental disease burden (World Health Organization 1993). Proportionally, malaria caused 9% whiles acute respiratory infections caused 19% of mortality among under five year old children worldwide in 2001 (WHO, 1993). These two are also the lead contributors to the burden of febrile illness in children. About 300 to 500 million clinical cases of malaria occur each year worldwide, approximately 2 million of which are fatal, primarily in children. The vast majority of malaria-related deaths are due to infection with Plasmodium falciparum. It is estimated that 200 people, primarily children in Africa, (which is hyper endemic for malaria) die of malaria every hour of everyday all year round. It has been estimated that countries in tropical Africa account for approximately 80% of all clinical cases and more than 90% of asymptomatic cases world-wide (World Health Organization, 1991, World Health Organization, 1993). The malaria situation is acute-on-chronic in the West African Sub region and is one of the main obstacles to its socio-economic development. In the first two months of life, children may not contract malaria, or even if contracted, the manifestations may be mild with low-grade parasitemia, due to the passive immunity offered by maternal antibodies. In endemic and hyper endemic areas, the parasite prevalence rate increases with age from 0 to 10% during the first three months of life to 80 to 90% by one year of age and 1 University of Ghana http://ugspace.ug.edu.gh the rate persists at a high level during early childhood. The mortality rate is highest during the first two years of life. By school age, a considerable degree o f immunity would have developed and asymptomatic parasitemia can be as high as 75% in primary school children, and this increasing resistance to infection and disease with age is conventionally thought to reflect a slow and gradual acquisition of protective immunity. Fever in infants has been defined as axillary temperature of 37.5°C or higher. In older children, an axillary temperature of 38°C or an oral temperature o f 37.8°C is generally considered abnormal. In the tropics, the main causes o f fever are bacterial, viral and malarial infections. 1.2 Rationale for Study Malaria is endemic in Ghana. It is one of the major causes o f morbidity and mortality, accounting for 40% o f all out patient visits. (Ahmed, 1989). Children five years and below suffer the most morbidity and mortality. Studies on malaria mortality have shown that deaths occur predominantly among young children and that malaria mortality rates among patients is consistently high, with hospital case fatality rates varying from 5% to 30% in established centers. Such mortality rates in established centers may be higher still in rural areas with little or no established health care facilities. Severe falciparum malaria is the commonest cause o f death in infants and children in areas endemic and hyper endemic for malaria. Inadequate immunity results in rapid increase in the parasite count and development of complications. Delay in diagnosis and treatment also contributes to this problem. 2 University of Ghana http://ugspace.ug.edu.gh Roll Back Malaria (RBM), a health strategy developed by the World Health Organization (WHO, 1998), and its partners, advocates four technical approaches, supported by low cost interventions to reduce malaria mortality and morbidity through improved prevention. These are: 1. Prompt access to treatment, especially for young children 2. Prevention and control of malaria in pregnant women 3. Vector control 4. Prediction and containment of epidemics Another strategy by WHO and the United Nations Children’s Fund, UNICEF, Integrated Management of Childhood Illnesses (IMCI) has been developed to offer an integrated approach to child health, that focuses on the well being o f the whole child. It recognizes that in the developing world, children brought to seek medical treatment often suffer from more than one condition, making a single diagnosis impossible. The proper use o f insecticide-treated nets combined with prompt treatment of malaria in the community can reduce malaria transmission by 60% and the mortality rate in young children from all causes by at least 20% (WHO, 2003). There is an urgent need to make effective antimalarials available to those most at risk. The drugs needed exist but those who need them most urgently do not have access to them and only a small proportion have bed nets treated with effective insecticides. Improvement in existing disease management and prevention methods for children is critical as well as the development of methods / tools to improve access to prevention, 3 University of Ghana http://ugspace.ug.edu.gh early treatment and referral of malaria to the bulk of rural dwellers in the primary health setting. 1.3 Purpose of Study The purpose of this study is thus to draw attention to the contribution o f malaria and bacterial infection to the burden of febrile illness among under five year olds in a primary health care setting. 4 University of Ghana http://ugspace.ug.edu.gh Chapter Two 2.0 LITERATURE REVIEW 2.1 Malaria and Bacterial Infections Bacterial infection and malaria are both major health problems in tropical countries and represent the two most common causes of fever in children in those countries. It is therefore not surprising that concurrent infections with these two common pathogens should occur. Malaria typically presents with fever that may be accompanied by chills and headache. Symptoms and signs may be subtler in partially immune and immune children. Anaemia and hepatosplenomegaly may also be present. Children may also present with respiratory distress and/or rapidly progressing cerebral malaria that manifests as altered sensorium and sometimes with seizures. Thick blood smears help to determine when infection is present, but a single smear without parasites is not sufficient to rule out malaria. Thin blood smears identify the species of the malaria parasite. Patients diagnosed with malaria can suffer from other bacterial or protozoan diseases as either super-infections or co-infections. Some bacterial infections are differential diagnosis for malaria, the classical being typhoid fever. Manifestations of secondary infections and of malaria can overlap. Fever, cough, diarrhea and dysentery can be seen in malaria, making the identification of the secondary infections rather difficult. There is a long history of proposed interactions between malaria and typhoid fever, which to a certain extent, had been explained away as the result of false positive Widal serologic 5 University of Ghana http://ugspace.ug.edu.gh tests in acute malaria infection (Widal test may show positive titers up to 1:320 dilution even in malaria.). (Jhaveri et al., 1995, Khubnani et al., 1995). Most bacterial infections in children over 3 months are caused by Streptoccocus pneumoniae (in non-immunised children), Neisseria meningitidis, Haemophilus influenzae and Salmonella species(Green, 1998). A study in Gambia, also suggested that co-infection was not common (Enwere et al., 1998), but, in most parts of the world where malaria is rampant, so many other infectious diseases are also prevalent, sometimes resulting in co-infection rather than super­ infection. Persistence of fever even after 48-72 hours o f correct antimalarial treatment and reduction in parasitemia should raise the possibility o f concomitant infections. Neutrophilic leukocytosis in the absence of severe falciparum malaria may indicate bacterial infection. Typhoid fever is difficult to differentiate from other causes o f infection such as malaria because their signs and symptoms often overlap. In a cross-sectional study carried out to determine the prevalence of typhoid fever in 200 consecutive patients with fever and symptoms clinically compatible with typhoid fever to verify recent estimates of a high prevalence of typhoid fever in Cameroon, Nsutebu et al (2003) enrolled 207 patients in three of the 10 provinces of Cameroon. Blood culture, thick and thin blood smears and Widal tests using acute sera were performed in all cases and stool culture for 120 patients. Typhoid fever was confirmed in only 2.5% as evidenced either by culture (four cases) or high salmonella antibody titers (one case); malaria was diagnosed in 94 (47%) patients. It was concluded that Typhoid fever is not as endemic in Cameroon as recently feared. 6 University of Ghana http://ugspace.ug.edu.gh 2.2 Some Immunological aspects of malaria Malarial infection has depressant effect on the immune system. In addition, falciparum malaria can be predisposing factor for certain specific infections. These associated infections are more common in patients with P. falciparum malaria. Recent studies, however, from Cameroon, Malawi, and Ghana have suggested that there may indeed be more interesting interactions between P. falciparum and bacterial infection (Salmonella species to be specific) than mere coexistence in the same individual host (Ammah et al., 1999, Commey et al., 1994). This phenomenon has been explained by immunosuppression due to acute malaria infection, which may lead to loss of control to colonising bacterial species with resultant bacteraemia. Acute malarial parasitemia has a profound immuno suppressant effect, probably through the activation of suppressor T cells. In a malaria endemic area, young children may suffer from severe infections (viral like measles or bacterial) due to this immunosuppression. 2.3 Malaria In their study “The impact of malaria diagnostic algorithm and poly pharmacy”, Marfo et al (1998) found that prescribers diagnosed malaria in 78.9%of children with fever in the wet season and 74.5% of children reporting at out patient clinics. The signs and symptoms commonly presented by those children diagnosed with malaria are vomiting, fever (temperature of 37.5 C), cough, headache pallor and body weakness. Out of 231 slides, which were positive for malaria parasites, only one was plasmodium 7 University of Ghana http://ugspace.ug.edu.gh malariae, the rest were plasmodium falciparum. Parasite densities ranged from 27/ul to 396/ul. Parasite density had no correlation with the temperature at presentation. Tarimo et al (2001) found that in many holo-endemic areas, it is unclear whether laboratory tests to confirm that such signs are the result o f malaria would be very relevant or useful. Children from a holo-endemic region of Tanzania were therefore checked for malarial parasites by microscopy and by using two rapid immunological tests. At the time they were tested, each of these children had been targeted for antimalarial treatment. Only 70% of the 395 children classified to receive antimalarial drugs by the IMCI algorithm had malarial parasitaemias (68.4% had Plasmodium falciparum trophozoites, 1.3% had only P. falciparum gametocytes, 0.3% P. ovale and 0.3% P. malariae). As indicators of P. falciparum trophozoites in the peripheral blood, fever had a sensitivity of 93.0% and a specificity o f 15.5% whereas pallor had a sensitivity o f 72.2% and a specificity of 50.8%. Wherever the effective drugs for the first-line treatment o f malaria are cheap (e.g. chloroquine and Fansidar), treatment based on clinical diagnosis alone should prove cost saving in health facilities without microscopy. Childhood fever is a common symptom, (Chong et al (1996)) reflective o f multiple causes. The majority of febrile children have non-bacterial upper respiratory tract infection and indiscriminate use of antibiotics is inappropriate, ineffective and leads to drug-resistance such as the emergence of Penicillin-resistant Streptococcus pneumoniae. The need to know when to use antibiotics appropriately at the primary care setting is critical especially at the primary care setting where laboratory support may be lacking. The need to identify a simple approach using the presence or absence o f associated or localising symptoms though serious bacterial infections can still occur despite 8 University of Ghana http://ugspace.ug.edu.gh unremarkable physical findings. Management o f fever needs to take into account the toxicity, immune status and age o f the patients as well as the source o f the infection. Nkuo et al (2002) investigated the prevalence of asymptomatic malaria parasitaemia and anemia in nursery and primary school Out of 297 nursery and primary school children two to 11 years old selected: the prevalence o f asymptomatic malaria in children was 30.3%. Parasite prevalence and density was independent o f age and sex. In the study Clinical diagnosis of Plasmodium falciparum among children with history o f fever, Sindh, Pakistan. Hozhabri et al (2003) examined 438 children with a history o f fever at a primary care setting in Pakistan. 6% were slide positive for malaria. An algorithm comprised o f fever 3 days duration and (absence o f cough or having rigors) had 100% sensitivity and 63% specificity for detecting P. falciparum. It was concluded that in this low malaria prevalence region, restricting the diagnosis o f malaria to persons who had >3 days o f fever and absence of cough or rigors, remained highly sensitive but was more specific than current practice. 9 University of Ghana http://ugspace.ug.edu.gh Chapter Three 3.0 STUDY PROTOCOL 3.1 Study Objectives 3.11 GENERAL • To determine the proportion of febrile illness attributable to malaria in children 6­ 60 months old presenting at the Dodowa Health Center 3.12 SPECIFIC • To document the clinical parameters associated with the diagnosis o f malaria at the center • To document the contribution of concurrent bacteria infection to clinical malaria. 3.2 Definition of Clinical Malaria Clinical Malaria Presentation at a clinic with a history of fever or fever (axillary temperature > 37.5C) plus i) 5 or more P. falciparum parasites per HPF (approx. 2500 /|il) ii) No other obvious cause found for the fever 10 University of Ghana http://ugspace.ug.edu.gh 3.3 Study Site Malaria is endemic in Ghana as in most of sub-Saharan Africa. This study was carried out at the Dodowa Health Center. It is situated in the Dangme West district, a rural district in the Greater Accra Region, on the coastal belt o f Ghana. The Dangme West District is one of the 5 districts of the Greater Accra region. The district, with its capital at Dodowa is situated in the South-eastern part o f Ghana, and lies between latitude 5 degrees 45' south and 6 degrees 05' North and Longitude 0 05 East and 0 degrees 20 West. It shares boundaries with the Yilo Krobo District on the North West, North Akwapim District on the West, Tema District on the Southwest and Dangme-East District on the East. The Volta River and the Atlantic Ocean wash the northeastern and the southern portions of the district respectively. It has a coastline stretching over 37 kilometers The District has a total land area of 1,700 squared kilometers, making it the largest out of five districts in the Greater Accra Region. The vegetation is mainly coastal savannah though there is a patch o f forest in the Dodowa sub-district The main occupation being fishing, food processing, stone quarrying crop and livestock farming. 68% percent of the district is classified as rural and 32% as urban. The district has a population of 96,015 (2000 census) with a projected growth o f 3%. The district is subdivided into four sub-districts for administrative purposes. Each sub-district is served at least by a health centre, but there is no hospital in the district. Referrals from the health centres and community clinics go to hospitals in surrounding districts. 11 University of Ghana http://ugspace.ug.edu.gh Malaria transmission in Dodowa is hyper-endemic but with marked seasonal variation (Afari et al, 1994). The main rainy season, June to July is the peak season for malaria transmission and has a higher incidence of malaria and the highest incidence rates are among those under 10 years (Afari et al, 1995). A one-year survey conducted at Dodowa in 1992 put the incidence rate of clinical malaria at 106.6 per 1000 population (Afari et al, 1995). The Dodowa Health Center serves the Dodowa Sub-district. A team, headed by the Medical Assistant in Charge mans it. 3.4 Study Design: 3.41 TYPE OF STUDY Descriptive 3.42 STUDY POPULATION Children aged 6 - 6 0 months who presented ill at the Dodowa Health Centre during July and early August 2003 3.43 SAMPLE All those children 6-60 months who presented with fever (axillary temperature >37.5C) and whose caregivers gave consent to participate in the study during the study period. Within the sample, those with temperatures above 40.0C had blood cultures for concurrent bacteria infection. 12 University of Ghana http://ugspace.ug.edu.gh 3.44 KEY PARAMETERS FOR ILL CHILDREN a. Prevalence of fever. b. Prevalence o f positive blood film for malaria parasites. c. Prevalence of positive blood cultures for bacteria 3.45 SAMPLE SIZE CALCULA TION n=Z2(p)(q) d2 •Prevalence of malaria as 20%= p, and q = 1- p Z=1.96 (confidence interval o f 95%) Error margin =d =10% Sample size, n = 61 3.46 SAMPLING STRATEGY All those satisfying the study inclusion/exclusion criteria on presentation and whose attending caregivers consented to take part were enrolled into the study. 3.47 RECRUITMENT Cases were recruited at the Dodowa Health Center. For the study, a case was defined as a child between the ages o f 6 to 60 months, who presents at the center with fever (axillary temperature of 37.5 C or above) during the study period. Once identified the study doctor assessed each child, and obtained consent from the parent or caretaker for inclusion into the study. If consent was given and the child fulfilled all the entry criteria and had none of the exclusion criteria, s/he was enrolled into the study. 13 University of Ghana http://ugspace.ug.edu.gh Inclusion Criteria • Child aged between age 6-60 months with a presenting axillary temperature o f 37.5 C or above at the Dodowa Health Center between July - August 2003. • Parental Consent from caretaker or parent to enroll into study. Exclusion criteria • Impaired sensorium • Severe dehydration • Other conditions that need urgent referral. 3.5 Laboratory Evaluations and Blood Draws All procedures were done under aseptic conditions using sterile disposable supplies with adequate haemostasis secured. The following table breaks down the blood requirements for the various aspects of this study in each o f the cases. 3.51 Blood requirements: Case 1- Those with axillary temperature between 37.5 and 40.0 C Case 2- Those with axillary temperature 40.0 C and above 14 University of Ghana http://ugspace.ug.edu.gh Test . Case 1 Case 2 Blood Culture - 2ml Blood smear 200 |al 200 ul Total 200 ju.1 2.2ml 3.52 Laboratory Methods Thick and thin blood smears were done for all participants using finger prick or venous blood. The blood smears; thin and thick were stained using 3% Giemsa solution for 30 minutes. Thin smears were used to identify for parasite identification whiles the thick films were used for parasite counts. The parasite density was scored against 200 white blood cells (wbc) and converted to parasites per microliter (ul) by assuming a wbc count o f 8000/ul. Blood cultures were transported by road to the Department o f microbiology of the University of Ghana Medical School on the same day. 3.6 Data Management & Statistical Analysis • Structured questionnaires were administered by the study doctor once a child has been recruited into the study by a nurse (screened and consent obtained from the adult accompanying the child) to the adult accompanying the child. 15 University of Ghana http://ugspace.ug.edu.gh • Physical Examination were done on the children and entered into physical examination report forms. • Analysis o f Blood films were done at the Dodowa Health Center laboratory whiles blood cultures were done at the University o f Ghana Medical School, Department of Microbiology laboratory. • Coding o f Data and Entry • All the study data was captured onto case record forms bearing subject demographic and identification numbers. All the forms were edited and checked by the study investigator and errors corrected before data entry. Data entry was done. • Analysis was done with EPI INFO (2000) and SPSS (version 10) 3.7 Limitations The researcher’s inability to cover the sample size (especially for the blood cultures) due to time constraints limits the generalization of the study results. The limitation of the period of data collection to the wet season also limits the generalizations o f the results of the study. Intra and inter observer errors may have occurred. This was minimized by training of nurses who took part in the study. All the questionnaires and physical examinations were done by the study doctor to prevent inter observer errors. The blood smears were done by one technologist and were 16 University of Ghana http://ugspace.ug.edu.gh read by two technologists at different times and the differences that arose were reconciled. The generalization of this study is limited due to the above limitations. 17 University of Ghana http://ugspace.ug.edu.gh Chapter Four 4.0 RESULTS 4.1 General Characteristics Fifty (50) children aged between 6 and 60 months were enrolled into the study .The gender is as follows. Table 1; Sex of participants N=50 Frequency Percen t Male 30 60.0 Female 20 40.0 Total 50 100.0 Figure 1. Age group distribution of participants. 401--------------------------------------------------------------------------------------------- 6-12 Months 20-26 Months 34-40 Months 48-54 Months 13-19 Months 27-33 Months 41-47 Months 55-60 Months GROUPS 18 University of Ghana http://ugspace.ug.edu.gh The mean weight is 11.44 kg (range is 6 - 20 kg). The mean height is 85.64 cm (range is 64 - 1 10cm). Ten percent (10%) of the children were being cared for, primarily by their grandmothers, 86% by their mothers and 4%by others (aunts). Eighty percent (80%) o f the caregivers are married, 12% are single and 8% are divorced. Table 2; Occupation of Caregivers N=50 Occupation of caregivers Frequency Percent Cumulative Percent Farming 9 18.0 18.0 Government 2 4.0 22.0 service Hairdresser 2 4.0 26.0 Housewife 2 4.0 30.0 Seamstress 9 18.0 48.0 Stone quarry 1 2.0 50.0 Trading 25 50.0 100.0 Total 50 100.0 Fifty two percent (52%) of the primary caregivers o f the children did not complete basic formal education. Table 3 gives the details. 19 University of Ghana http://ugspace.ug.edu.gh Table 3; Distribution of Formal Education levels attained by Primary Caregivers N=50 Caregiver's Education Level Frequency 0-3 years 16 Primary 9 4-6 years JSS 1 (7-8 years) Basic 20 (9 years) Post Basic 4 (10-15 years) Total 50 Percent Cumulative Percent 32.0 32.0 18.0 50.0 2.0 52.0 40.0 92.0 8.0 100.0 100.0 4.2 Case Histories and Examinations Recent Past Medical History of Children Twenty (20) percent o f the children have been hospitalised, 4% for anaemia and blood transfusion, 6% for convulsions, 8% for malaria and 2% for others. In 62% of the children, caregivers had given some form of treatment before coming to the clinic, but only 30 % gave an antimalarial, (chloroquine) which was obtained mainly from the drug stores in the respective communities. 50% of those who were given chloroquine were given adequate doses for 3 days. 2% gave antibiotics and 8%gave multivitamins. 20 University of Ghana http://ugspace.ug.edu.gh Presenting signs and symptoms In 54% of cases, respondents complained o f vomiting, diarrhoea in 20% of cases, chills in 32.7 o f the cases and inability to suck or eat in 56% of cases. Forty eight percent (48%) had liver enlargement, 16% had the spleen enlarged, 2% had visible jaundice, 48% had pale conjunctivae, 2% had moderately impaired hydration status and 2% had oedema. The mean axillary temperature recorded was 38.53 C (SD 2.889). The highest recorded temperature was 40 C (in 8% o f cases) Blood Smear Results Ninety six (96) percent of the patients had positive blood smear results for malaria parasites (all o f them had plasmodium falciparum species). The mean parasite density was 3541.74 counts per ul. The minimum and maximum parasite densities were 80 and 28,800 counts/ul respectively, but only 28% had parasite densities above 2500/ul, (the clinical diagnosis cut off point) The proportion of patients with parasite densities above 20, 000/ul is 4%. These were aged 40 months and above. About 75% of those with parasitaemia had parasite densities 3240/ul and below. 21 University of Ghana http://ugspace.ug.edu.gh Figure 2distribution of mean parasite densities (count/ul) among the age groups 14000 12000 10000 8000 S 6000 c <1) T3 £! 4000 'r above recruited into a study, 96 % had positive blood smears for plasmodium alciparum, but only 28% had parasite densities above 2500/ul to satisfy the clinical liagnosis criteria. Malaria is thus a significant contributor to febrile illness in children 6 -60 months jresenting at primary care setting in Ghana. 6.2 Recommendations 1. There is the need for further studies into the contribution o f bacterial infections to febrile illness in children. This will prevent misdiagnoses and the inappropriate prescription of antibiotics especially at primary care centers where a misdiagnosis may mean death for some children as they might not make it back to the health center 2. There is the need to intensify the training on IMCI guidelines to cover all prescribers in the primary care settings. 3. The use o f insecticide treated bed nets by families, especially those with children under five years be encouraged and promoted actively in the Dangme West District. 4. Caregiver education on management of malaria at home needs to be intensified. 25 University of Ghana http://ugspace.ug.edu.gh REFERENCES: 1. Ahmed, K. 1989. Epidemiology of malaria in Ghana. Ghana Med. J. 23:190­ 195. 2. Marfo, C. Asante, M; Arhinful, S; 1998. The Impact o f Malaria diagnostic Algorithm on Poly-Pharmacy and cost. Unpublished 3. Ortega, L.I; Binka F. 1994. Clinical Parameters Associated with the Diagnosis o f Malaria in PHC Settings. Unpublished 4. WHO- (1991) Report on a meeting on the application o f rapid assessment methods to tropical diseases, WHO/SER/RAM/91.3. Geneva:UNDP/ World Bank/ WHO Special Programme for Research and Training in Tropical Diseases. 5. 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West Afr J Med. 1998 Jan- Mar: 17(1): 15-8 11. Tarimo DS, Minjas JN, Bygbjerg IC. Malaria diagnosis and treatment under the strategy of the integrated management of childhood illness (IMCI): relevance of laboratory support from the rapid immunochromatographic tests of ICT Malaria P.fTP.v and OptiMal. Ann Trop Med Parasitol. 2001 Jul; 95(5): 437-44. 12. Chong CY, Allen DM. Childhood fever. Singapore Med J. 1996 Feb; 37(1): 96-100. 13. Anonymous, www.malariasite.com/543/children.htm. Malaria in Children. 14. Anonymous, Malaria Kills 3000 Children a day in Africa. Bull WH Organ, 2003, vol 81 810.6 p.472-42, ISSN 0042- 9686 15. Artavanis-Tsakonas K, Tongren JE, Riley EM. The war between the malaria parasite and the immune system: immunity, immunoregulation and immunopathology. Clin Exp Immunol. 2003 Aug; 133(2): 145-152 16. Nkuo Akenji TK, Ajame EA, Achidi EA. An investigation of symptomatic malaria parasitaemia and anaemia in nursery and primary school children in Buea District Cameroon.Cent Afr J Med. 2002 Jan-Feb;48(l-2):l-4. 27 University of Ghana http://ugspace.ug.edu.gh 17. Nsutebu EF, Martins P, Adiogo D. Prevalence o f typhoid fever in febrile patients with symptoms clinically compatible with typhoid fever in Cameroon. Trap Med Int Health. 2003 Jun;8(6):575-8. 18. Hozhabri S, Luby SP, Rahbar MH, Akhtar S.Clinical diagnosis of Plasmodium falciparum among children with history o f fever, Sindh, Pakistan. Int J Infect Dis. 2002 Sep;6(3):233-5. 19. http://www.mosquito.who.int/cgi. . ,/dhome rbm.jsp 20. http://www.who.int/child-adolescent-health /integer.htm 21. Jhaveri KN, Nandwani SK, Mehta PK, Surati RR, Parma BD. False positive modified Widal test in acute malaria. J Assoc Physicians India. 1995 Nov;43(ll):754-5. 22. Ammah A, Nkuo-Akenji T, Ndip R, Deas JE. An update on concurrent malaria and typhoid fever in Cameroon. Trans R Soc Trop Med Hyg.1999 Mar-Apr ;93(2):127-9 23. Khubnani H, Phalke D, Khubnani AH, Jain RC. Coexistence o f anti - Salmonella agglutinins in falciparum malaria. J Assoc Physicians India. 1995 Aug;43(8):585-6 24. Enwere G, Van Hensbroek MB, Adegbola R, Palmer A, Onyiora E, Wood, Greenwood B. Bacteremia in cerebral malaria. Ann Trop Paediatr. 1998 Dec; 18(4): 257-8 25. Green M. Fever In: Pediatric diagnosis. Philadelphia: Saunders, 1998: 203 26. Commey J, Quarm-Goka B, Agyepong 1. Persistent Fever in severe malaria in children. Cent Afr J Med. 1994 Sep; 40(9): 257-60 28 University of Ghana http://ugspace.ug.edu.gh 27. Afari EA, Dunyo S, Appawu M, Nkrumah FK. IN vivo seasonal assessment o f Plasmodium falciparum sensitivity to chloroquine in two different malaria endemic communities in southern Ghana. Afr J Health Sci. 1994 Aug;l(3):l 12-115 28. McGowan JE Jr, Bratton L, Klein JO, Finland M. Bacteremia in febrile children seen in a "walk-in" pediatric clinic. N Engl J Med 1973; 288: 1309­ 12 29. McCarthy PL, Sharpe MR, Spiesel SZ, Dolan TF Jr. Observation scales to identify serious illness in febrile children. Pediatrics 1980; 65: 1090-5 30. Afari EA, Appawu M, Dunyo S, Baffoe -W ilmot A, Nkrumah FK. Malaria infection, morbidity and transmission in two ecological zones in Southern Ghana. Afr J Health Sci. 1995 May; 2(2): 312-315 31. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics o f fever in selected infants. N Engl J Med 1993; 329: 1437-41 32. Baraff LJ. Management o f fever without source in infants and children. Ann EmergMed 2000; 36: 602-14 33. Bachur R, Harber MB. Reevaluation of outpatients with Streptococcus pneumoniae bacteremia. Pediatrics 2000; 105: 502-9 34. Jones RG, Bass JW. Febrile children with no focus of infection: a survey of their management by primary care physicians. Pediatr Infect Dis J 1993; 12: 179-83 29 University of Ghana http://ugspace.ug.edu.gh 35. Itzhak Brook, Unexplained fever in young children: how to manage severe bacterial infection, BMJ 2003; 327:1094-1097 (8 November), doi: 10.1136/bmj.327.7423.1094. 30 University of Ghana http://ugspace.ug.edu.gh 35. Itzhak Brook, Unexplained fever in young children: how to manage severe bacterial infection, BMJ 2003; 327:1094-1097 (8 November), doi: 10.1136/bmj.327.7423.1094. 30 University of Ghana http://ugspace.ug.edu.gh APPENDICES l. Consent to participate in a research project form INTRODUCTION AND BACKGROUND We are from the Dodowa Health Center and are about to conduct further studies into malaria in this community and would like to invite your child/ward to take part in this study. A germ that is passed from one person to the other by the bite of a mosquito that carries the malaria germ causes malaria. Malaria is a very serious health problem in Ghana. The disease strikes people of all ages, male or female. It can be particularly severe in children and may cause death. To understand this problem we need to study children who come to the health center with malaria. All children younger than five years old who come to the hospital with fever will be invited to take part in the study. Taking part in the study involves having a little blood, about half teaspoonful of blood drawn from the arm of your child or ward to check for malaria germ and other germs in the blood. Taking part is completely voluntary; you are not required to participate. You have every right to refuse. If you should refuse it is all right. Whether or not you participate in the study your child/ward will receive the same, appropriate medical care for malaria at the health centre. This study will be carried out over approximately two months, beginning in June 2003 and will involve participation of about 100 children. We would like to invite your child to take part in the study. Take your time and read this consent form or have it read to you. You must ask and receive satisfactory answers to all of your questions, if you have any. Your child will be one of up to 60 volunteers to take part in this study. Your child’s/ward’s taking part is entirely University of Ghana http://ugspace.ug.edu.gh voluntary, and you may withdraw him or her from the study at any time without penalty. We are hopeful that the knowledge gained may be of benefit to all in the community. CONFIDENTIALITY The medical information collected shall be used only for the purposes of this study. We will collect data on forms provided specifically for this protocol. QUESTIONS You are encouraged to ask questions at any time before and during the study. If you have any questions concerning this study, you may contact the following persons; 1. Dr Alberta Amu Quartey, Dodowa Health Center 2. The Medical Assistant, Dodowa Health Center 3. Dr. Irene Agyepong District Health Management Team Dangme West Dodowa b University of Ghana http://ugspace.ug.edu.gh SIGNATURE OF VOLUNTEER WILLING TO PARTICIPATE I have read all of the above or have had this document read to me, asked questions, received answers concerning areas I did not understand, and am willing to give consent for my child/ward to participate in this study. I will not have waived any of my rights by signing this consent form. Upon signing this form, I will receive a copy of this consent document for my personal records. Name of participant or ward................................................................................. Name of parent(s)/guardian............................................................................................. Signature/Left parent/guardian Thumbprint University of Ghana http://ugspace.ug.edu.gh 2. Blood Smear Results Form Study Identification no. Hospital Identification no. RESULTS # Parameter 1 Parasitaemia l.Yes 2. No 2 Species l.PF 2.PM 3.PO 3 Count /200wbc 4 Trophozoites/200wbc d University of Ghana http://ugspace.ug.edu.gh 3. Questionnaire Section A STUDY IDENTIFICATION NUMBER HOSPITAL IDENTIFICATION NUMBER Name of Child. Sex 1. Male 2. Female Age (in months) 1.6-24 2. 25-60 Comm un ity/Residence. Name of Respondent... Relationship of Primary Respondent to Child: 1. Mother 2. Father 3. Other (specify) University of Ghana http://ugspace.ug.edu.gh N am e o f careg ive r. Relationship of Primary Caregiver to Child: 1. Mother 2. Grandmother 3. Other (specify) Number of years/months Primary caregiver has lived with Child: Number of years of formal education of primary caregiver: Occupation of primary caregiver: 1. House wife 2. Farming 3. Trading 4. Government/ 5. Other Public service Marital Status of primary caregiver: 1. Married 2. Single 3. Divorced 4. Separated 5. Widowed f University of Ghana http://ugspace.ug.edu.gh Section B Recent Past Medical History 1. Have you given/ gone for treatment for the child somewhere before coming to the health center 1. Yes 2. No 3. Home 4. Herbalist /traditional healer/ Religious healer 5. Health Facility 6. Others 2. Treatment given: 3. Has this child had malaria treatment this past week? 1. Yes 2. No 9.NK (If no, go to 9) 4. Date treatment started: (dd/mm/yyyy) 5. Source of the malaria drug administered: g University of Ghana http://ugspace.ug.edu.gh 1. Clinic 2. Market 3. Drug store 4. Peddler 5. Other 6. Name of malaria drug administered: 1. Chloroquine 2.Fansidar 3. Camoquine 4. Artesunate 5. Other 7. Duration of the malaria treatment (in days) 8. Dose given Adequate 1. Yes 2.No 9. Hospitalization 1. Yes 2. No 99. NK 10. If Yes, reason for hospitalization/admission: 1. 2. 3. 4. 5. 6. Short of blood Convulsion Respiratory infection Diarrhoea Malaria Other h University of Ghana http://ugspace.ug.edu.gh Section C Presenting symptoms 11. Fever 1. Yes 2. No 12. Shaking chills/rigors 1. Yes 2. No 13. Diarrhoea (3 or more watery stools) 1. Yes 2. No 14. Vomiting 1. Yes 2. No 15. Joint pains 1. Yes 2. No 16. Cough 1. Yes 2. No 17. Difficult in breathing 1. Yes 2. No 18. Bloody urine 1. Yes 2. No 19. Inability to suck /drink /eat 1. Yes 2. No 20. Inability to sit/stand unaided 1. Yes 2. No 21.Convulsions. 1. Yes 2. No University of Ghana http://ugspace.ug.edu.gh 4. PHYSICAL EXAMINATION REPORT FORM STUDY IDENTIFICATION NUMBER: CASE CODE 1. Respiration (number/minute): 2. Axillary Temperature ( C): 3. Pulse / (minute): 4. Systolic blood pressure (mmHg) 5. Diastolic blood pressure (mmHg): 6. Weight (Kg): 7. Height / Length (cm): 9. Presence of Oedema J University of Ghana http://ugspace.ug.edu.gh 1 = Ascites, 2 = Facial, 3 = Pedal, 4 = General, 8 = NA 11. Hydration Status: 1. Normal 2. Some 3. Severe impairment Impairment 12. Pallor: 13. Jaundice: 14. Respiratory distress: 2. Absent 15. Spleen enlarged 1. Yes 2. No 16. Liver size (cm): 17. Lethargy 18. Convulsions 1. Present 2. Absent 1. Present 2. Absent k University of Ghana http://ugspace.ug.edu.gh 19. Restlessness 20. Consciousness 1. Clear 2. Unconscious/se miconscious Blood Samples taken Yes No Blood Culture Blood smear Total I University of Ghana http://ugspace.ug.edu.gh