Using an Educational Training Module to Increase Knowledge, Attitudes and Practices of Malaria among Medicine Vendors in Yobe, Nigeria

2.1 General facts about malaria

You may be wondering why the emphasis on improving knowledge, treatment and prevention. The main reason is because malaria, being a life-threatening parasitic disease affects parts of the world we live in and remains the major public health problem in Nigeria. It is an avoidable cause of death and illness in children and adults. In Nigeria, malaria continues to be endemic and is the first major cause of morbidity and mortality among the most vulnerable groups- children under 5 years, pregnant women and people living with HIV/Aids. Malaria is characterised by a stable, perennial, transmission in all parts of the country. Transmission is higher in the wet season than in the dry season. This seasonal difference is more striking in the northern part of the country.

According to the World Malaria Report (2013), there was a worldwide estimate of 207 million cases of malaria and an estimated 627 000 deaths in 2012 alone. 81% of these cases and 91% of the deaths were from sub-Saharan Africa [5], and Nigeria alone bears up to 25% of the burden [6]. Again, about 63% of hospital attendance in the Nigerian health care facilities are caused by malaria which is also the cause of absence in workplace / schools, in addition to a huge health expenditure to households leading to a total estimated economic loss to the country of up to 132 billion Naira per year [6].

Note that, in the absence of an effective vaccine, malaria treatment and prevention still remains the vital strategies of malaria control, especially to you PMVs, who are usually the first place of call to the bulk of community residents.

• What is Malaria?

□ Malaria is a serious and sometimes fatal disease caused by a parasite called plasmodium which infects human blood cells. (A parasite is an organism that can only exist in the body of another organism for all or part of their life)

□ There are 4 main kinds of plasmodium parasites that cause malaria in humans. These are:

• Plasmodium falciparum (Pf).

• Plasmodium vivax (Pv).

• Plasmodium malariae (Pm).

• Plasmodium ovale (Po).

In Nigeria 98% of malaria infections are due to P. falciparum. This parasite causes the most deadly form of malaria, known as severe malaria. Other forms of malaria present in Nigeria include P. ovale and P. malariae which play a minor role with the latter being quite common as a double infection in children.

Note THAT:

□ Malaria is NOT caused by body contact, drinking contaminated water or eating any kind of food as is the assumption in some localities.

□ Neither is malaria caused by staying under the sun, exposure to cold weather or living in a dirty environment. Though, these conditions can aggravate malaria.

2.2 Types of vector mosquitoes

There are three common types of Mosquito Vectors:

1. Anopheline mosquito

   □ wings with dark spots

   □ sits at an angle of 45 degree with the resting surface

   □ breeds in clean water

   □ bites at late night

   □ transmits malaria

2. Culex mosquito

   □ usually are referred to as nuisance mosquitoes

   □ usually found to breed in dirty waters

   □ no unique dark spots found on the wings (usually plane dark wings)

   □ appears with a hunchback when in sitting position

   □ usually transmits filariasis

3. Aedes mosquito

   □ are usually dark ornamental mosquito with unique white spots

   □ usually breeds in clean waters found in containers / overhead tanks and wells

   □ usually bites during the day time

   □ bite from this specie is usually very painful

   □ transmits Dengue/DHF/Chikungunia which are viral diseases

2.3 Life cycle of malaria parasite and the malaria transmission cycle

The vectors that carry malaria parasites (mosquito) prefer to feed on humans rather than other animals. Another unique characteristic is that the vectors prefer to feed indoors. While taking a blood meal, the female mosquito injects saliva into the person’s blood vessels to stop the blood from clotting to make it easier to suck in. While injecting saliva, if she is infected with malaria parasites, she injects them as sporozoites into the person’s blood as seen in Figure 1. On the other hand, if the person is infected, when the mosquito draws up the blood it will also take up malaria parasites as gametocytes, the sexual forms of the malaria parasite. After a blood meal, the female mosquito usually finds a place to rest (usually the wall of the house) to digest her meal, and to develop her eggs. The malaria parasites which have been sucked up from the blood as gametocytes develop inside the mosquito over a period of 8 to 25 days to become sporozoites in the salivary glands. At this stage the female Anopheles mosquito becomes infective to the next person it feeds on.

Once the sporozoites get into a person with no or little immunity to malaria, they undergo various stages of development to cause disease about 7 to 12 days later as seen in Figure 1. Specifically, the sporozoites travel rapidly to the liver where they enter the liver cells and divide rapidly, forming merozoites. When a liver cell is full of merozoites, it bursts and discharges the merozoites into the blood where they quickly enter the red blood cells. In the red blood cells, the merozoites grow and divide again until the red blood cell bursts to release them into the blood stream to attack other red blood cells. This is what causes the person to experience symptoms such as fever, sweating and shivering. Some merozoites, however, change into the male and female forms of the parasite, called gametocytes, which are taken in by the mosquito when she sucks the blood to get her blood meal (Figure 2). The gametocytes enter the mosquito’s stomach and mate to form eggs, which then in turn become sporozoites and move to the mosquitoe’s salivary glands where they are ready to be injected into another person. Once the mosquito bites a person and infects him or her with sporozoites, it takes about 8 to 11 days for gametocytes to appear in the blood. In this way and under suitable conditions, one female Anopheles mosquito can transmit malaria parasites to many susceptible people during its average life span of 20 to 25 days [7]. This transmission cycle is illustrated in Figure 2 below. In this way, this cycle of transmission continues unless interventions are used to break it.

2.4 Brainstorming exercises

Note: Facilitator will ask these questions and different opinions from participants discussed.

Why is malaria a major public health problem in Nigeria.

Answer: Because Malaria is a major cause of:

□ Ill health (morbidity)

□ Death (mortality)

□ Impaired child development

□ Absenteeism in school children and work places

□ Lost productivity (estimated economic loss to Nigeria is 132 billion Naira per year)

□ Lost opportunities for economic development, e.g. tourism and foreign investment.

How is this Anopheles mosquito specie different from other mosquitoes?

Answer: It is a large mosquito and when standing it is tilted with head downwards and tail upwards in the air.

Which people are most vulnerable to Malaria?

Answer:

□ Pregnant women

□ Children under 5 Years of age

□ People living with HIV/AIDS

□ People suffering from Sickle Cell disorders

□ Travellers into malaria endemic areas

Note: The first two groups (Pregnant women & Children below 5 years) are most at risk within our communities because of their low immunity and the malaria endemic nature of Nigeria, as such malaria is even regarded as mainly a maternal, new-born and child health issue.

Why does only the female mosquito transmit the disease?

Answer: The female mosquito needs a blood meal for the nutrients to develop her eggs.

Do other biting insects such as flies transmit malaria?

Answer: No. Only the female mosquito transmit malaria.

List 3 factors or reasons why people who have malaria die.

Answer:

□ Delay in starting treatment

□ Inappropriate treatment (wrong drug, incorrect dosages, non-compliance)

□ Failure to recognise and manage complications

What is the difference between Suspected Malaria and Confirmed Malaria?

Answer:

Suspected Malaria: A patient with a fever or history of fever in the last 24 hours who lives in, or has come from anywhere in Nigeria or any other endemic country. Previously, all patients with this definition of malaria were given treatment with an antimalarial. Now, however, the best practice is to test all patients with suspected malaria with a confirmatory test before giving treatment.

While Confirmed Malaria: A patient with suspected malaria who has been shown to have malaria parasites through a parasitological test such as microscopy (using a blood smear) or rapid diagnostic test (RDT).

What is the difference between uncomplicated malaria and severe malaria?

First: Ask participants to differentiate between the two.

Answer:

Uncomplicated Malaria is a situation where a patient presents with a history of fever, or a fever in the last 48 hours, with no signs of severity or evidence of vital organ dysfunction but with a positive confirmatory parasitological test;

While in severe malaria, a patient presents with a positive confirmatory parasitological test and presentation of one or even more symptoms of the severe disease state (see 3.1 below).

2.5 Reflections on this module

Think about the topics you have just been discussing. How will you use the new knowledge you have gained when you go back to your premises? Use the questions below to help you reflect on this. Record your thoughts on paper for discussions.

1. What is simple malaria?

2. What have I learned about malaria today that I did not know before I came to this training program?

3. How will this new information be useful when I go back to work?

4. What other questions do I now need to ask the trainer and get answers for?

5. What questions do I have about how I will use this information when I go back to my community?

3.1 Signs and symptoms of malaria

Signs and symptoms of uncomplicated malaria

Fever is usually the main symptom of malaria. It can be reported by the patients themselves or parents of children (could be even when the temperature returns to normal when being examined) or ascertained by taking the temperature (equal to or higher than 37.5° under the armpit or up to 38° rectally).

The signs and symptoms that may occur in uncomplicated malaria include:

□ Headache

□ Fever

□ Sweating

□ fatigue and dizziness

□ loss of appetite

□ muscle and/or joint aches

□ chills / Rigours

□ perspiration

□ digestive disorder: such as diarrhoea, abdominal discomfort

□ nausea, vomiting

□ worsening malaise

These signs and symptoms can be identified by asking the patient or their caregiver what they have noticed since the patient started the episodes of illness. The PMV and other healthcare providers can also take the patient’s vital signs, including their temperature. Figure 3 shows presentations of a patient with malaria as it transits from shivering to profuse sweating.

Signs and symptoms of severe malaria

Malaria is said to be severe or complicated when a patient presents with one or several of the under listed signs and symptoms:

□ very high temperature (could be >40° C)

□ Prostration (i.e. generalised weakness that patient is unable to sit or walk)

□ severe anaemia (nomocytic type: a very common complication)

□ consciousness disorders (confusion, agitation, drowsiness and coma)

□ multiple convulsion (>2 in last 24 hrs)

□ repeated vomiting (hindering oral treatment),

□ dehydration (thirst, dry lips, sunken eyes and deep set fontanel),

□ icterus (jaundice),

□ dark (coca-cola) coloured urine

□ Renal failure

□ hypoglycaemia

□ breathing difficulties

□ spontaneous bleeding

Other clinical signs could also appear such as anaemia, acute renal injury, acute pulmonary oedema /Adult Respiratory Distress Syndrome (ARDS), circulatory collapse or shock, abnormal bleeding (e.g. bruising, bleeding gums, haemoglobinurea).

Cerebral Malaria is a common presentation of severe malaria and may cause residual problems. A patient with malaria and altered level of consciousness, confusion, delirium, hallucinations or frank coma with or without convulsion is said to have cerebral malaria.

Note that:

□ Malaria always causes fever and therefore any fever should be suspected to be due to malaria in endemic areas.

□ All cases of pregnant women and children below 5 years of age presenting with malaria are considered as severe malaria.

□ All patients presenting with conditions listed above for complicated malaria or that which you do not fully understand, please REFER PATIENT IMMEDIATELY!

3.2 Diagnosis of malaria

3.3 Case studies

Activity 3.3.1

Instructions for the facilitator:

1. Divide the class into four groups, ask participants of each group to study the case studies below on the description of patient’s signs & symptoms, diagnosis, misdiagnosis and appropriate suggestions from a trained PMV (allow 10 minutes to discuss & 5 minutes for each group to present).

2. Ask what the patient is suffering from.

3. Note the various points raised by participants and use them to discuss the various cases.

4. If the participants suspect that the patient has malaria, how do they arrive at such conclusions?

   NB. It is important to find out how they confirm this. Encourage them to emphasise the need to test.

5. Conclude the session by discussing each group’s presentation

Note that:

• RDTs are fast, convenient and can be handled by an incompetent hand. RDTs are fairly cheap and do not require electricity.

• They are thus convenient for use by PMVs where it will improve their services with resultant avoidance of unnecessary treatment and over-treatment with antimalarials.

Activity 3.3.2 Read and discuss the case studies below.

Case study 1: An unknown patient comes to your PMV shop and complains that he has fever, headache, and joint pains. He continued that the fever has been coming on and off for about three days but he usually feels fine during the day and in the evening he has fever.

What is he/she is suffering from and what is your line of action?

Case study 2: A mother comes to your premises with a 3 year old child that looks very weak. The child had vomited severally and on checking, you found the child had 40° C. discuss your actions.

3.4 Demonstration exercise

Demonstration of the use of RDT to show purple/red line in test and control windows on strip showing antigen–antibody reaction if positive. Discuss advantages of RDTs mentioned earlier.

3.5 Reflection on the module

Participants are asked to make think about the topics they have just discussed. How will they use the new knowledge gained when back to their premises? Also use the questions below to help reflect. Record the thoughts on paper for discussions.

1. What is RDT and how do you compare it to microscopy?

2. What have I learned about malaria today that I did not know before I came to this training program?

3. How will this new information be useful when I go back to work?

4. What other questions do I now need to ask the trainer and get answers for?

5. What questions do I have about how I will use this information when I go back to my community?

4.1 National treatment protocol

What is the National Malaria Treatment Protocol about?

Answer: The national treatment protocol contains recommendations on the most effective treatment that should be given for malaria. The current protocol recommends Artemisinin-based Combination Therapy (ACT) as the most effective treatment for uncomplicated malaria instead of Chloroquine and SP.

4.2 Why government changed 1st line malaria treatment from CQ to ACTs?

CQ and SP are no longer effective in treating malaria in Nigeria due to high treatment failures resulting from widespread resistance. Efficacy studies that test the ability of antimalarial medicines to kill and clear malaria parasites have shown that ACTs are better than chloroquine. Table 6 below describes the two older drugs that are no longer indicated for malaria treatment.

Artemisinin derivatives are the most effective drugs against malaria in the world at the moment and yet if misused the parasites can potentially develop resistance to them. Already there are some signs from Far East Asia that improper use and use of poor quality ACTs is making the malaria parasites have some ability to withstand treatment with ACTs causing cure to take longer to achieve.

A technique to prevent resistance developing to Artemisinin derivatives is to combine them with other antimalarials so that as a combination there is less possibility of the parasites developing mechanisms to avoid both medicines.

Note that: The objective of prompt and effective malaria treatment is to:

• Cure the disease and eliminate the parasites from the body

• Prevent progression to severe disease or death

• Prevent transmission to others

• Prevent the parasites developing resistance to the malaria treatment

• Minimise adverse drug reactions

4.3 The first line treatment of malaria

Below are details of the treatments for malaria as recommended by the Government of Nigeria:

4.4 Second line treatment

The second line treatment for malaria in Nigeria is Quinine in tablet formulation. The indication for using Quinine is where a patient has confirmed malaria and has already taken a full course of the first line antimalarial treatment, i.e. AM / LM or AS+AQ, and has not recovered. Parasitological confirmation of the diagnosis should be done with microscopy before prescribing oral Quinine.

Dosage: Quinine tablets (300 mg salt) are given as a dose of 10 mg/kg body weight up to a maximum dose of 60 kg body weight, e.g., 600 mg every 8 hours for 7 days.

4.5 Good prescribing practices

NOTE THAT:

□ Malaria can be 100% cured by ACTs, but ONLY when used appropriately

□ The only ACTs recommended in the National Protocol are AM/LM and AS+AM.

□ It is not advisable to use other non-recommended ACTs.

□ Artemisinin monotherapies are not recommended as treatment for uncomplicated malaria.

□ Use of antimalarials by patients that do not have malaria means patients are taking medicines that they do not need, which could be dangerous.

□ Overuse of antimalarials also has economic consequences to patient & the nation

It is good practice to strongly encourage the client to take a full course of treatment and complete the dose, otherwise the patient will not get well. This means that you, as the health provider, need to counsel the client by providing health information and advice.

Clients need to know about:

□ the type of treatment they are receiving

□ how to take/give the medicine

□ the dosage required

□ importance of completing treatment

□ details of how to watch out for adverse drug reactions

Dosing advice to healthcare providers regarding treatment of their clients:

□ Always dispense the full 3-day course of medicines

□ Show the client how to split the tablet (if necessary) to get the correct dose. This can be done by pressing a knife along the seam on the top of the tablet

□ If possible, have client take the first dose in front of you, so you can supervise as needed

□ Refer the client to health facility if they have any indications for referral.

Dosing advice to healthcare providers regarding treatment of their clients:

□ They should always take the medicine with or right after meals with a full glass of water

□ When using a co-packaged (two different drugs together) product, both medicines must be taken together in correct doses.

□ To completely cure the illness, the full course of treatment (the correct number of tablets taken at the correct number of times each day for the correct number of days) must be taken.

□ Symptoms may not disappear immediately after taking the first dose. Improvement may take up to two days.

□ If the client vomits within half an hour, then the dose should be repeated.

□ The client should take plenty of fluids to avoid dehydration and food to maintain strength. Fluids that contain sugar or glucose are an advantage.

□ For small children, it helps to crush the tablets and mix it with fruit juices, or sugar and clean water to make a solution that is easier to swallow.

4.6 Demonstration exercise

Observe the commonly available ACTs and discuss dosage presentations, so also how to crush and split tablets for children (where necessary).

4.7 Group quiz

The facilitator will divide the class into four groups and each group will present their answers to the quiz question below:

1. What is the drug of choice used in the treatment of uncomplicated malaria in Nigeria excluding pregnant women?

   Answer:

   The anti-malarial drug of choice is: Artemeter - Lumefantrine (AL).

   Alternatively: Artesunate + Amodiaquine (AA).

2. What drugs are used for severe malaria treatment?

   Answer:

   □ Parenteral drugs (IM or IV route) are required

   □ IM or IV Quinine is the drug of choice.

   □ Injectable Artemether is an alternative choice

   □ Dosages are given in the treatment guidelines.

3. Which drug is used for treatment failure?

   Answer:

   □ Oral Quinine (after laboratory confirmation and ruling out other causes of fever)

   □ In pregnancy depending on the alternatives available and the trimester of pregnancy (refer to Guidelines).

4. What drugs are used for treating uncomplicated malaria in pregnancy & What is the dose?

   Answer: Artesunate-Amodiaquine or Artemether-Lumefantrine in the 2nd and 3rd trimesters; Quinine tablets or Quinine-Clindamycin in the first trimester of pregnancy. Refer to guidelines for dosage.

5. What drug is used for Intermittent Preventive treatment (IPT) of malaria in pregnancy?

   Answer: Sulphadoxine - Pyrimethamine (SP) (Discuss why …..Refer to treatment guidelines).

4.8 Role play

A volunteer from the class will be the health provider in a premises. Another volunteer pretended to be a client presenting with malaria symptoms. On provision of a complete ACT regimen, the client decides to take and pay for an incomplete treatment.

What will be your response in the situation and how will you convince the client?

4.9 Reflection on module

Think about the topics you have just been discussing. How will you use the new knowledge you have gained when you go back to your premises? Use the questions below to help you reflect on this. Record your thoughts on paper for discussions.

1. Outline the treatment of both uncomplicated and severe malaria?

2. What other treatments have you learnt today?

3. How will this new information be useful when you go back to work?

4. What other questions do you now need to ask the trainer and get answers for?

5.1 Conditions requiring referral

The indications for referral from a primary to a secondary or tertiary health facility are when:

□ One or more danger signs are present

□ The patient has features of severe malaria

□ The patient is on recommended malaria treatment, but there is no improvement after 48 hours

□ The client is not complying with treatment, because of vomiting or are otherwise unable to take drugs by mouth

□ The client has adverse drug reactions to the ACT medicine that prevents him / her from taking / completing treatment

□ You are unsure of the client’s illness or condition

□ The patient is having fever every day for seven or more days

Those patients who are not severely ill but have one or more indications for referral should be referred with a referral form / letter. Patients who are severely ill as shown by the presence of danger signs or features of severe malaria should be given pre-referral treatment.

5.2 Treatment failure

The recurrence of P. falciparum malaria usually results due to either a re-infection or recrudescence / failure. Failure in treatment is defined as the failure to effectively clear malaria parasites from the blood or can also be described as the inability to resolve clinical symptoms despite administration of antimalarials. Treatment failure can result from so many causes.

• Vomiting or poor absorption of drug – the patient or the caregiver usually gets confused on what to do should the drug get vomited.

• Poor practices in prescribing – prescribing of incomplete course of treatment increases the risk of treatment failure in malaria. This is a common practice with PMVs. So always insist patients take home full / complete treatment regimen, with proper advice on need to complete dose.

• Poor adherence: which may be due to several factors, including:

  • information on correct regimen could be unclear to the patient or caregiver ab-initio;

  • some patients choose to stop taking treatment once the pressing symptoms have resolved (a common problem with drugs having a very rapid symptoms clearance), and some patients share the remaining treatment with their family / friends;

  • in cost-recovery systems, some patients cannot even afford a complete course of their treatment, this presents a big challenge;

  • Except for co-formulated products, patients may discard one of the components of the combination that is associated with side effects or taste hence its ineffectiveness.

• Drug quality – the use of substandard antimalarials with inadequate recommended amount of active ingredient is a particular risk for drug. So ACT quality must always be ensured by:

  • sourcing from reputable pharmaceutical outlets or their representatives;

  • proper storage all through the distribution system to avoid exposure to high temperatures; and

  • Avoiding administering expired drugs.

• Drug resistance in this case is the ability of a given parasite to survive or multiply despite drug administration and absorption in doses equal to or higher than the usually recommended, but within the tolerance of the subject.

Though treatment failure within 14 days of treatment with an ACT is very unusual, a good history and proper examination is necessary to confirm any non-malaria related causes of symptoms (refer to module 2). For instance, was a complete course of ACT really taken, accompanied by food or not where appropriate, and without vomiting in the first hour following any dose? So also, all treatment failures must be confirmed parasitologically, and preferably by taking blood slides for examination.

Note THAT, it is very important to keep good records of all confirmed treatment failures and this information forwarded to appropriate health authorities, as these failures need to be imputed into drug efficacy studies and these studies usually lead to the observed changes in first-line antimalarial treatment.

• Whenever the treatment failure is after 14 days of initial treatment, it should be considered to be a re-infections and another dose of ACT can be given.

• Treatment failures within 14 days of initial treatment should be treated with a second-line antimalarial such as Quinine (for a total of 7 days).

5.3 Danger signs

Generally, all danger signs are dangerous as the name indicates and emphasis is on the need for an immediate referral. The most common danger signs include:

• Convulsions or fits within the last two days or at present

• Not able to eat / drink or breastfeed (in children)

• Vomiting everything taken (severe vomiting) or severe diarrhoea

• Prostration indicated by extreme weakness, unable to sit or stand

• Altered mental state such as lethargy, drowsiness, confusion or unconsciousness

• Breathing difficulties

• Severe dehydration shown by sunken eyes or if skin is pinched

• Severe anaemia or lack of blood shown by pale lips or palms

Note that:

All patients who have danger signs need urgent treatment at a secondary or tertiary healthcare facility that has the equipment and expertise to handle emergency conditions. To save this patient, you need to refer immediately.

5.4 Pre-referral treatment

All patients especially children who do not respond to treatment (with AL within 24 hours) and the very ill (i.e., having any danger signs or features of severe malaria) shall be referred immediately to the nearest hospital. Time is important at this point and every hour of delay reduces the patient’s chance of survival. Pre-referral treatment is used to increase the chance of the patient surviving long enough to get to the health facility for further treatment.

5.5 Demonstration exercises

• A sample of Artesunate Suppository is torn to show participants its presentation and the insertion process is described.

• Filling of Referral forms; done as a group work

Note that: Pre-referral treatment is not a replacement treatment for severe malaria.

6.1 Reasons for prevention

• Malaria can kill if it infects an individual, so we try to prevent it.

• Malaria will make you sick, and therefore make you unable to work, so people may lose jobs /miss school etc.

• Malaria leads to poverty because Malaria and poverty are connected, you cannot work and earn money or go to school for your future if you are ill with Malaria, and you will need to spend a lot of money for treatment.

Note that:

• The first step towards malaria control is prevention.

• It costs far less to prevent malaria than it costs to treat it.

What must you do as a healthcare provider to help your clients prevent malaria?

• Provide health education to your community. As a health care worker you can provide community members with information on prevention methods that are available so that they can take steps to prevent malaria.

• Be a good example to the community by using the preventive methods you are advocating, especially the ITNs.

What about the long awaited Vaccine for malaria?

An effective vaccine is not yet available for malaria, this is because of the different phases which the parasite does exist within the human body giving it different / contrasting properties. Although several vaccines are under development. So far, a prospective vaccine candidate known as RTS-S/AS01 has shown potentially promising results in clinical trials in Africa. Evidence-based policy recommendations on the issue are expected to be made this year (2015) depending on data that will become available. While this wait goes on, prevention will then depend on how to avoid parasites getting into the body.

How do we stop parasites getting into our body?

The mosquitoes that spread malaria tend to bite at night between the hours of 10 p.m. and 4 a.m. They prefer to feed on human blood. After feeding, the mosquitoes rest inside the house, usually on the walls. Common ways of preventing malaria take advantage of these characteristics of the mosquito vector.

Key elements for transmission of malaria (as discussed in module 1.3) are:

• The malaria parasite itself,

• The transmitting agent (i.e. the vector mosquito), and

• The reservoir of the disease (i.e. people carrying the parasites in their blood).

The general objective of preventive efforts are:

1. Reducing vector-host contact: Since the mosquito must feed once on an infected host to acquire the malaria parasite and once on an uninfected person to transmit it, reducing host-vector-host contact is an effective way of reducing transmission.

2. Reducing the longevity and abundance of adult mosquito population: The more the mosquito population in an area the greater is the probability of transmission. So, reducing the longevity and abundance of adult mosquito population in an area reduces probability of transmission.

3. Reducing suitable breeding sites (source reduction) wherever this is feasible and sustainable.

How effective these strategies are will greatly depend upon how assiduously they are applied. The Federal Ministry of Health in Nigeria has adopted and prioritised these prevention strategies: Insecticide Treated Nets (ITNs), the Intermittent Preventive Treatment (IPT) for pregnant women, Complementary and increasing Indoor Residual Spraying (IRS), Environmental Management and larval Source Management (to reduce breeding where significant proportions of breeding sites can be identified and targeted). They are the key prevention strategies to be discussed.

Finally, there are on-going research initiatives looking to find new ways to tackle malaria. For example, many scientists are involved in the search for new drugs and vaccines (as stated earlier), which will be safe, effective, and with affordable price tags, that could change our thinking on conquering malaria. Similarly, due to drug-resistance, particularly with Plasmodium falciparum, new medications are constantly being tested. A combination of all efforts towards fighting malaria put together had reduced the mortality of malaria greatly over the years; the major aim now for governments and all other partner organisations such as the WHO, Roll Back Malaria (RBM), Society for Family Health (SFH), Malaria No More (MNM), etc. is to get to a point where deaths from malaria are eliminated through effective treatment and prevention strategies.

6.2 Insecticide treated nets (ITNs)

An ITN provides effective barrier between the person who is sleeping under it and the mosquito vector. It reduces the opportunity for mosquito to bite and infect. The impregnated insecticide also acts to kill and repel any susceptible vector that rests on the net. An Integrated Vector Management System (IVMS) for malaria prevention is also in place in the country and is a combined approach involving the distribution of Insecticide Treated Nets (ITNs) as the major approach this involves all form of deliveries such as free public sector donation campaigns either jointly integrated with other health activities (such as vaccination campaigns, National immunizations) or as stand-alone campaigns, to the free public sector routine distributions such as ANC and EPI services, and the subsidised and at cost sales through hospitals, clinics and at PMV outlets.

Insecticide treated bed nets can be either conventional ITNs or Long Lasting Impregnated Nets (LLINs). Conventional ITNs, as the name implies must be treated once or twice a year (usually dependent on the duration of the transmission). LLINs are nets, whose fabrics have been impregnated with insecticides by a special technique from the source, so that the insecticidal effect is maintained for as long as the net can withstand daily usage, i.e. usually 3–5 years or about 20 washes. Figure 4 below shows an example of an impregnated bed net hung outside to protect people from vector transmission within a garden. Total access to LLIN is the ultimate aim in public health and public sector distributions focuses on children under 5 years of age and pregnant women.

6.3 Intermittent preventive treatment (IPT) during pregnancy / special care patients

Currently, the most preferred intervention to prevent malaria in pregnancy is the use Intermittent Preventive Treatment (IPT) apart from ITNs. And this is based on the use of anti-malaria drugs that are usually given in treatment doses at some defined intervals after quickening (16 gestational weeks). This serves to reduce malaria parasitaemia which usually leads to poor pregnancy outcomes. IPT with other products like haematinics and anthelmintics are preferably provided as part of a comprehensive antenatal package. Every pregnant woman should also have access to insecticide treated nets (ITNs) in addition to the IPT, which should be used throughout the pregnancy as an additional method of malaria prevention.

Drug of Choice for Intermittent Preventive Treatment (IPT) Sulphadoxine - Pyrimethamine (SP) is a combination drug (Sulphadoxine 500 mg + Pyrimethamine 25 mg) and shall be reserved only for Intermittent Preventive Treatment (IPT).

6.4 Indoor residual spraying (IRS)

Indoor residual spraying with an insecticide is sprayed on the wall every four or six months to kill mosquitoes that rest on the wall to digest its blood meal. Before and after feeding on a person, the mosquito rests on the wall where it picks up some of the insecticide which eventually kills it. IRS is a very effective way of preventing malaria.

Although this method is complementary to ITN distributions, it will form an important and increasing part of the preventive strategy. Scenarios that are potential focus for IRS include:

• Areas where IRS has advantages to ITNs or has a synergistic effect (e.g. in and around densely populated cities).

• Areas having a short and usually a malaria transmission season which is limited and where the addition of the sprays can make local elimination possible (e.g. the Sahel savannah in the North-East of this country).

• Areas where using treated nets shows to be difficult to implement (e.g. consistent low use rates found with some communities).

• Institutions with marked populations such as boarding schools, army and police barracks etc. the use of ITN seems more challenging in such places.

6.5 Other vector control interventions (environmental & Larval source management)

These include Environmental Management (EM) and Larval control strategies by using larvicides, predators or growth inhibitors.

6.6 Demonstration session

• Demonstration on the appropriate spread of the ITN to suite both indoor or outdoor use

• Demonstration on the proper method of treatment of the ITN using Deltamethrin.

6.7 Brainstorming session

• What advice would you as a PMV give a patient about prevention of malaria?

Answer:

• Use of insecticide treated materials should be encouraged.

• Mosquito screening devices in house designs and protective dressing.

• Use of insecticides and mosquito repellents.

• Environmental management especially destroying mosquito breeding sites.

• Which role can you play in the prevention and management of malaria in the community?

Answer:

Discussions should be along these lines:

• Case management aspect

• Vector control, Behaviour Change Communication

• Health education and Community participation