Malaria Prevention

#### **Chapter 6**

## Bio-Efficacy of Insecticide-Treated Bednets (ITNs) Distributed through the Healthcare Facilities in a Boundary Community in Nigeria

*Ezihe K. Ebuka, Emmanuel Obi, Nwangwu C. Udoka, Ukonze B. Chikaodili, Nwankwo N. Edith, Udezue Nkemakonam, Egbuche M. Chukwudi and Okeke C. Peter*

#### **Abstract**

This study was conducted to evaluate the susceptibility and efficacy of three insecticidal treated bednets; Olyset®, PermaNet2.0® and MAGNet® collected from the different health facilities, against *Anopheles* mosquitoes under laboratory conditions. PermaNet3.0 was used as a positive control. Larval collections were carried out and reared at the insectary of National Arbovirus and Vector Research Centre, Enugu State. *Anopheles Kisumu* mosquitoes were used as the standard control in the cone bioassay test. The bioassay showed that the wild *An. gambiae* s.l. and *An. gambiae* Kisumu strains were susceptible (100% mortality) to the PermaNet3.0® used as positive control while the wild-caught *Anopheles* were resistant to the mono-treated ITNs. The mortality effect of the net brands showed that the brands have a statistically significant effect on the mosquito mortality after 24 hours *F* (2, 18) = 14.32, *p* < .001), while the sides of the net did not have a statistically significant effect on the mosquito mortality (*F* (3, 18) = 1.67, *p* = .209). This study also suggests the need to develop and adopt routine monitoring of the ITNs at the health facilities, as it will inform the replacement of ineffective nets. However, a mass campaign of PBO nets is necessary for the state to achieve and maintain the universal coverage of ITNs.

**Keywords:** bednet, efficacy, bioassay, malaria, Nigeria

#### **1. Introduction**

Noticeable progress has been made in the fight against malaria and most of this progress can be attributed to the scale-up of malaria control interventions. The interventions include insecticidal treated nets (ITN), indoor residual spraying

(IRS), chemo-prevention for pregnant women and children and treatment with artemesinin-based combination therapy [1]. Insecticide-treated nets (ITNs) are a widely used tool that has been proven to be effective in the prevention and control of malaria in malaria endemic countries [2].

ITNs are mosquito nets treated with insecticides that do not require any reimpregnation. They are designed to retain their efficacy against mosquito vectors for a minimum of 3 years or 20 standard washes under laboratory conditions [3, 4]. However, it has been recommended that ITNs should be made available to all individuals at risk in endemic areas, regardless of age, universal access [5, 6], which is defined as the availability of one mosquito net for every two individuals [7]. Of the 663 million cases that were avoided owing to malaria control interventions between 2001 and 2015 in sub-Saharan Africa, it is estimated that 69% were circumvented with the use of ITNs, 21% with artemisinin-based combination therapy, and 10% with IRS [8].

Between 2008 and 2016, more than 1 billion ITNs have been distributed in Africa through mass campaigns and replacement programmes; and the scale-up has contributed immensely to the drop in malaria incidence by 68% [9, 10]. WHO recommends that countries maintain universal coverage through a combination of health facility distribution and continuous distribution through community-based channels [3].

Monitoring the insecticide performance of the ITNs distributed through a mass campaign is a priority for the Integrated Vector Management (IVM) sub-committee of the National Malaria Elimination Programme (NMEP), as studies have confirmed insecticide survival time rate of 3–4 years in Nigeria [11], 2.5 years in Tanzania [12], 3.1–3.3 years in Zanzibar [13] and 2.5–3 years in Zambia [14].

The study aims to determine the insecticidal effectiveness of the net sides and brands (PermaNet 2.0®, Olyset® net and MAGNet®) distributed through the primary healthcare facilities in the boundary community with known high pyrethroid resistance status using the WHO cone bioassay. The study also intends to compare the efficacy of the mono-treated nets (PermaNet 2.0®, Olyset® net and MAGNet®) with a PBO net (PermaNet3.0®).

#### **2. Methodology**

A cross sectional study on the efficacy of different sides and brands of ITNs (PermaNet2.0®, Olyset® and MAGNet) collected from the Primary Health Care (PHC) Centres were assayed. The PHCs includes Amechi-Idodo Health Centre, Ohani (6.44326'N, 7.71239′E) and Eziama Health Centre (6.41989'N, 7.71880′E) in Amechi-Idodo, Nkanu East of Enugu state, Nigeria. Two nets of each of the 3 net brands were collected from the health facility for the assessment.

Mosquito larvae were collected from the four communities (Eziobodo, Obinagu, Eziama and Ohani) in Amechi Idodo. A geo-referenced map of the collection points was created to show that these villages are contiguous as well as borders Ebonyi State, Nigeria as seen in **Figure 1**.

#### **3. Collection of** *Anopheles* **mosquito larvae**

The test requires a 2–5-day old female adult mosquito so the larval population of *Anopheles* mosquitoes were collected from the four communities. The larvae were

*Bio-Efficacy of Insecticide-Treated Bednets (ITNs) Distributed through the Healthcare Facilities… DOI: http://dx.doi.org/10.5772/intechopen.106577*

**Figure 1.** *Map of larval collection sites in Amaechi-Idodo, Nkanu east L.G.a.*

collected according to the method of Service (1993). The larvae collected from sunlit, open pools were carefully transferred in a slightly covered container to the insectary of National Arbovirus and Research Centre Enugu (NAVRC) where they were reared to adult.

The field-collected larvae were reared to the adult stage with part of the water from the breeding habitat according to Chukwuekezie et al. [15]. Care was taken to remove all the predators from the collections.

#### **4.** *Anopheles gambiae* **Kisumu colony used as standard**

*A. gambiae* s.s. (Kisumu strain) that has been characterized and demonstrated to be susceptible to insecticides was used for the bioassay. Insecticide resistance testing using the WHO test procedure [16] on the *An. gambiae* Kisumu strain takes place every three months to ascertain that the susceptibility of the mosquitoes to insecticides is maintained. The strain is colonized at the insectary of NAVRC, Throughout this period, the relative humidity and temperature were maintained at 80 ± 10% and 25 ± 2°C, respectively.

#### **5. Test insecticide treated nets (ITNs)**

#### **5.1 Olyset net**

Olyset® net is a pre-qualified net by WHO with 2% w/w of permethrin insecticide incorporated into the fibers of the nets. The net uses hybrid polymer and controlled insecticide release technology to repel, kill and prevent mosquitos from biting for up to five years.

#### **5.2 MAGNet®**

MAGNet® net is also a pre-qualified net by WHO with alpha-cypermethrin insecticide incorporated with the 150-denier high density Polyethylene (HDPE) filament which diffuses to the surface of the net slowly and this small amount released is enough to kill a mosquito.

#### **5.3 PermaNet®**

PermaNet 2.0® is a pre-qualified net by WHO. It is a knitted poly filament polyester fiber which are infused with deltamethrin.

#### **5.4 PermaNet3.0®**

PermaNet3.0® was used as positive control because of the synergistic effect of the PBO. It is made mainly of polyethylene fabric incorporated with 2.1 g/kg ± 25% of deltamethrin alone (on the upper sides) and 4 g/kg ± 25% of deltamethrin combined with 25 g/kg of a synergist piperonyl butoxide (PBO) on the roof and coated with 2.8 g/kg ± 25% of deltamethrin on the lower sides, also called borders. The lower sides are reinforced with polyester fabric [17].

#### **5.5 Cone test**

The WHO cone bioassay was carried out at the Entomology Laboratory of the National Arbovirus and Vectors Research Centre, Enugu. The cone test was used to assess the insecticidal effectiveness of the three WHO pre-qualified ITNs. The test was conducted following the WHO protocol. Four sub-samples (replicates namely the sides A, side B, Side C and the Roof) measuring 25 cm × 25 cm were cut from each of the three nets as indicated in **Figure 2**. The same net sides as seen in **Figure 2** were cut from an untreated bednet without insecticide and was evaluated alongside the assay. Each net was fastened to the cone and five non-blood-feed, 2–5-day-old

*Bio-Efficacy of Insecticide-Treated Bednets (ITNs) Distributed through the Healthcare Facilities… DOI: http://dx.doi.org/10.5772/intechopen.106577*

**Figure 2.** *Net sides and the roof of the net brands cut out for cone bioassay.*

female *Anopheles* mosquitoes were exposed to each piece of netting for 3 minutes according to the protocol of WHO [3]. The mosquitoes were then removed from the cones and transferred to resting tubes with access to 10% sugar solution. The number of knockdown (KD) was recorded every 10 minutes for up to 60 minutes after exposure and effective mortality was assessed 24 hours after exposure.

#### **6. Data analysis**

According to the WHOPES, the two main outcomes proposed in its guidelines to assess the bio-efficacy of LLIN on mosquitoes exposed for three minutes are: (i) mortality after 24 hours≥80%, and (ii) a KD rate after 60 minutes ≥95%. Although the standard protocol recommends using the two outcomes, i.e., mortality of 80% or KD ≥ 95% [3, 18].

The result were subjected to descriptive statistics such as mean and standard deviation (SD) to determine the average number of mosquitoes that died after 24 hours and those that were knocked down at 30 minutes and 60 minutes post-exposure to the different brands and different sides of nets. The Global Validation of Linear Model Assumption (GVLMA) was used to assess the data for conformity to linear model assumptions. Inferential statistics the analysis of variance (ANOVA) were used to compare the means of mosquito knockdown and mortality across the different groups of net brands (Olyset®, PermaNet2.0®, and MAGNet®), sides of the net (A, B, C, and roof), and mosquito status (wild or Kisumu). The interaction effect, simple main effect or main effect of the different groups on the mortality or knockdown of the mosquitoes were assessed, accordingly. BeforeThe Tukey's post hoc test was used for pairwise comparison of the means in groups that had statistically significant differences. Statistical significance was determined at 5% probability level (p < 0.05). However, for the simple main effect, statistical significance was determined at a probability level of 0.01 to avoid Type 1 error. The statistical analysis was performed in R version 4.1.1 [19], using the packages; dplyr [20], gvlma [21], ggplot2 (Hadley [22]), and emmeans [23].

#### **7. Results**

#### **7.1 Effect of net brands on the mortality of wild** *An. gambiae* **s.l. for different sides of the net**

Mortality observed with the positive control (PermaNet3.0®) for all the nets tested was 100% irrespective of the net side. On the other hand, the treatment

recorded the least mortality in MAGNet® for all the sides to which the mosquitoes were exposed. A two-way ANOVA was performed to analyze the effect of net brands and net side on the mortality of wild *An. gambiae* s.l. The result as shown in **Figure 3** revealed that there was not a statistically significant interaction between the effects of net brands and the net side (*F* (6, 12) = .92, *p* = .513). The main effect analysis showed that the net brands have a statistically significant effect on the mosquito mortality after 24 hours (*F* (2, 18) = 14.32, *p* < .001), while the sides of the net did not have a statistically significant effect on the mosquito mortality (*F* (3, 18) = 1.67, *p* = .209). Tukey's test for multiple comparisons revealed that the mean mortality was significantly different between Olyset® and MAGNet® (*p* = .003) and between PermaNet2.0® and MAGNet® (*p* < .001). There was no statistically significant difference in mean mortality between Olyset® and PermaNet2.0® (*p* = .495).

#### **7.2 Comparison of the effect of nets brands on the mortality of wild and susceptible** *An. gambiae* **s.l.**

Least percentage mortality with the wild mosquitoes was observed in MAGNet®, irrespective of the net side to which the mosquitoes were exposed to. A similar observation was recorded in the susceptible mosquitoes except for mosquitoes exposed to Side B, where the least percentage mortality was observed in Olyset®. It was shown in **Figure 4** that irrespective of the side of the net the mosquitoes were exposed to, the susceptible *An. gambiae* s.l. recorded higher mortality than the wild mosquitoes in all the nets tested. A two-way ANOVA was performed to analyze the effect of net brands and mosquito status on mortality. The result revealed that there was not a statistically significant interaction between the effects of net brands and mosquito status (*F* (2, 42) = 2.54, *p* = .091). The main effect analysis showed that the net brands and the mosquito status both have a statistically significant effect on the mosquito mortality after 24 hours (*F* (2, 44) = 16.60, *p* < .001 and *F* (1, 44) = 44.08, *p* < .001,

**Figure 3.** *Effect of net brands on the mortality of wild* An. gambiae *s.l. for different sides of the net.*

*Bio-Efficacy of Insecticide-Treated Bednets (ITNs) Distributed through the Healthcare Facilities… DOI: http://dx.doi.org/10.5772/intechopen.106577*

**Figure 4.**

*Comparison of the effect of nets brands on the mortality of wild and susceptible* An. gambiae *s.l.*

respectively). Tukey's test for multiple comparisons revealed that the mean mortality was significantly different between PermaNet® and MAGNet® (*p* = .001). There was no statistically significant difference in mean mortality between Olyset® and PermaNet® (*p* = .260) or between Olyset® and MAGNet® (*p* = .083).

#### **7.3 Knockdown effect (30 minutes post-exposure) of net brands on wild** *An. gambiae* **s.l. exposed to the different sides of the net**

The treatment recorded the highest knockdown (30 minutes) in mosquitoes exposed to Side C of both the PermaNet2.0® and MAGNet® nets as shown in **Figure 5**.

The result of a two-way ANOVA performed to analyze the effect of net brands and the side of nets on knockdown after 30 minutes revealed that there was not a statistically significant interaction between the effects of net brands and the side of the net (*F* (6, 12) = 1.13, *p* = .404). The main effect analysis showed that both the net brands and the side of the net do not have a statistically significant effect on the knockdown after 30 minutes (*F* (2, 18) = 1.08, *p* = .361 and *F* (3, 18) = .96, *p* = .433, respectively).

#### **7.4 Knockdown effect (60 minutes post-exposure) of net brands on wild**  *An. gambiae* **s.l. exposed to the different sides of the net**

In both PermaNet 2.0® and MAGNet®, the treatment recorded the highest knockdown (60 minutes) in mosquitoes exposed to Side B of the nets, while the least was observed on Side A as seen in **Figure 6**.

**Figure 5.**

*Knockdown effect (30 minutes post-exposure) of net brands on wild* An. gambiae *s.l. exposed to the different sides of the net.*

The result of a two-way ANOVA performed to analyze the effect of net brands and the side of nets on knockdown after 60 minutes revealed that there was not a statistically significant interaction between the effects of net brands and the side of the net (*F* (6, 12) = 1.49, *p* = .263). The main effect analysis showed that the net brands did not have a statistically significant effect on knockdown after 60 minutes of exposure (*F* (2, 18) = .13, *p* = .877). The net side, on the other hand, has a statistically significant effect on knockdown after 60 minutes (*F* (3, 18) = 4.46, *p* = .017). Tukey's test for multiple comparisons revealed that the mean knockdown (60 minutes) was significantly different between sides A and B (*p* = .006) only.

#### **7.5 Comparison of the knockdown (after 30 minutes) effect of nets side on wild and susceptible** *An. gambiae s.l*

Susceptible mosquitoes recorded a higher mean percentage knockdown (after 30 minutes) in all the nets tested. The result of a two-way ANOVA performed to analyze the effect of the side of nets and mosquito status on knockdown after 30 minutes revealed that there was a statistically significant interaction between the effects of the side of the net and the mosquito status (*F* (3, 40) = 10.35, *p* < .001). At an alpha level of .012, the mosquito status effect within the Side A group was statistically significant (*p* = .001). On Side A of the nets, the mean knockdowns after 30 minutes was 0 for the wild mosquito and 3 for the Kisumu as seen in **Figure 7**.

#### **7.6 Comparison of the knockdown (after 60 minutes) effect of nets side on wild and susceptible** *An. gambiae* **s.l.**

The result of a two-way ANOVA performed to analyze the effect of the side of nets and mosquito status on knockdown after 60 minutes revealed that there was a *Bio-Efficacy of Insecticide-Treated Bednets (ITNs) Distributed through the Healthcare Facilities… DOI: http://dx.doi.org/10.5772/intechopen.106577*

**Figure 6.**

*Knockdown effect (60 minutes post-exposure) of net brands on wild* An. gambiae *s.l. exposed to the different sides of the net.*

statistically significant interaction between the effects of the side of the net and the mosquito status (*F* (3, 40) = 4.5, *p* = .008). At an alpha level of .012, the mosquito status effect within the Side A group was statistically significant (*p* = .001). On Side A of the nets, the mean knockdowns after 60 minutes was 1 for the wild mosquito and 4 for the Kisumu. It was shown in **Figure 8** that the susceptible mosquitoes recorded a higher mean percentage knockdown (after 60 minutes) in all the nets tested.

#### **8. Discussion**

This study is one of the first conducted in the South-east of Nigeria to compare the response of local malaria vectors in a boundary community known to have pyrethroid-resistant malaria vectors to ITNs available in the health facilities. Pyrethroid insecticides used to treat nets have an excito-repellent effect that adds a chemical barrier to the physical barrier. The insecticide kills mosquito that encounters the ITNs, thus reducing the vector population [24]. Variations in the mortality of malaria vectors to different types of ITNs used for the study were generally low, especially with nets treated with pyrethroids only. Several studies have shown a decrease in the bio-efficacy of ITNs against local pyrethroid-resistant vectors [25, 26]. The highest mortality of 62.5% attained in the study with PermaNet2.0® is still below the 80% mortality and 90% KD60 approved by the WHOPES. The mortality recorded using PermaNet2.0® treated with deltamethrin was found to be significant compared to other net brands (Olyset® and MAGNet®). Irrespective of the sides of the net tested, higher mortality was recorded especially between Olyset® and PermaNet2.0® when the susceptible mosquitoes were exposed to the nets as compared to the mortality in

#### **Figure 7.**

*Comparison of the knockdown (after 30 minutes) effect of nets side on wild and susceptible* An. gambiae s.l*.*

#### **Figure 8.**

*Comparison of the knockdown (after 60 minutes) effect of nets side on wild and susceptible* An. gambiae *s.l.*

the wild mosquitoes. The findings observed in the study showed that mortality was brand-dependent and not side-dependent. However, the efficacy of ITN treated with alpha-cypermethrin (MAGNet®) was generally lower than that of the other ITNs

#### *Bio-Efficacy of Insecticide-Treated Bednets (ITNs) Distributed through the Healthcare Facilities… DOI: http://dx.doi.org/10.5772/intechopen.106577*

irrespective of the sides tested. *Anopheles* mosquitoes in Amechi-idodo was shown to be resistant to the pyrethroids in the PMI entomological surveillance studies [27], especially for the three insecticides used in impregnating the three brands of nets. According to the findings by PMI [27] in Amechi-Idodo, using WHO susceptibility bioassay showed that *Anopheles gambiae* complex in the study site had a mortality of 19% for Permethrin, 68% for alpha-cypermethrin and 84% for deltamethrin which are the insecticides used in impregnating Olyset®, MAGNet® and PermaNet2.0® respectively. The comparison of ITNs bio-efficacy performed in this study provides the necessary information for the selection of appropriate ITNs for mass distribution. The reduced efficacy of pyrethroid-only ITNs could be attributed to the selection pressures exerted using the same class of insecticide for pest control in agriculture which describes Amechi-Idodo as agrarian and as seen in the studies of [28, 29]. A similar finding was observed in southwestern Ethiopia by Yewhalaw et al. [25] and in Uganda [30] where the researchers recorded a reduced efficacy of mono-treated ITNs against wild-resistant *An. gambiae* s.l. in comparison with the response of the same mosquito population to PermaNet3.0® treated with deltamethrin + PBO. The new-generation ITN with pyrethroids and PBO (PermaNet3.0®) in the study showed higher efficacy than mono-treated ITNs (PermaNet2.0®, MAGNet® and Olyset®). However, the strong resistance of local vectors to pyrethroids especially deltamethrin suggests that the combination of deltamethrin + PBO will be the most appropriate strategy against local vectors in the study area for now. According to the findings of PMI [31], synergist test with PBO showed a complete restoration to pyrethroid susceptibility (54–98% for permethrin and 90–100% for deltamethrin) of *A. gambiae* s.l collected from Ohaukwu, an adjourning local government in Ebonyi state and this was observed in the study that the use of PBO net significantly showed an increased in the mortality of mosquitoes.

The results of this study, therefore constitute important evidence that can guide decision making in the selection and distribution of high-efficacy ITNs in the eastern region of Nigeria, as evidence has shown in the studies of [15, 32] that *A. gambiae* s.l is resistant to all pyrethroids. The use of ITNs that showed high bio-efficacy against the local vector populations should be encouraged to significantly reduce the transmission of malaria indoors. Indoor biting in the study area has shown to occur mainly from 10 pm to 6 am [27] and the infectivity rate in the neighboriong state is as high as 6.6%, highlighting the importance of ITNs [31] thereby a need for an efficient ITNs.

Despite the importance of our findings, there are some limitations. An epidemiological survey concerning the protection offered by the ITNs would have been ascertained to see the real efficacy of the nets in the study area. The evaluation of the efficacy of the ITNs would have been better if tunnel tests were conducted on nets, as none of the nets met the criteria of 80% mortality with resistant mosquito strains. Also, chemical analysis of the ITNs prior to the start of the study would have improved the quality of the results and also the effect of temperature and relative humidity on the stored ITNs and for how long will also help in answering the question of the low efficacy obtained.

This study recommends the need to develop and adopt routine monitoring of the ITNs at the health facilities, as it will inform the replacement of ineffective nets. However, a mass campaign of PBO nets is necessary for the state to achieve and maintain the universal coverage of ITNs as the Antenatal care and Expanded programme on immunization channels are no longer sufficient for the continuous distribution of ITNs.

### **Author details**

Ezihe K. Ebuka1 \*, Emmanuel Obi<sup>2</sup> , Nwangwu C. Udoka<sup>3</sup> , Ukonze B. Chikaodili4 , Nwankwo N. Edith<sup>5</sup> , Udezue Nkemakonam5 , Egbuche M. Chukwudi<sup>5</sup> and Okeke C. Peter<sup>6</sup>

1 Malaria Consortium, Abuja, Nigeria

2 PMI VectorWorks Project, Tropical Health LLP, Abuja, Nigeria

3 National Arbovirus and Vectors Research Centre, Federal Ministry of Health Enugu, United States

4 School of Biological Science, Universiti Sains, Malaysia

5 Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka, Nigeria

6 Opec Research Consult, Awka, Anambra State, Nigeria

\*Address all correspondence to: eziheebuka@yahoo.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Bio-Efficacy of Insecticide-Treated Bednets (ITNs) Distributed through the Healthcare Facilities… DOI: http://dx.doi.org/10.5772/intechopen.106577*

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#### **Chapter 7**

## Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children

*Andrew Macnab*

#### **Abstract**

Robust evidence indicates school-aged children are particularly vulnerable to malaria and need special measures to protect them. Calls are widespread for better diagnostic approaches and innovative programs that benefit children, because current levels of malaria-related morbidity and mortality are so high. Problematically, most national malaria control programs do not specifically target school-aged children; although the literature describes options for child-focused strategies, there is no consensus on the optimal intervention; and where a strategy is advocated, it is almost always one identified through systematic review. While understandably the scientific "gold standard," such reviews exclude many potentially useful and valid approaches, because reports describing them do not meet the inclusion criteria of being randomized controlled trials. Such trials are inevitably limited in number due to cost and complexity, and many excluded reports describe locally developed innovation based on World Health Organization diagnostic and therapeutic guidelines with the potential to benefit children. This chapter frames how practical interventions such as these can be put in place by school communities, and in parallel, how approaches advocated by the WHO and Lancet Commission to promote health literacy and access to essential health services can create ways to reduce the burden of malaria on school-aged children.

**Keywords:** artemisinin combination therapy, cognitive impairment, intermittent protective treatment, health promotion, rapid diagnostic testing, seasonal malaria chemoprophylaxis, school-based prophylaxis, task shifting, teachers, WHO health promoting school (HPS) model

#### **1. Introduction**

Malaria exemplifies how health inequity negatively impacts children's lives and their ability to benefit from education. While global investment in recent years to fight malaria has led to millions of malaria deaths being averted, and this progress has certainly benefited young children [1], bold decisions are still needed to control the

disease [2], and especially to meet the longstanding calls for specific interventions to reduce the burden of disease in school-age children [3–6]. Overall, policies to address the high prevalence of malaria infection in this age group are lacking, and school-age children continue to attract little attention as a group in need of special measures to protect them [4, 7].

Although leading authors have recommended that malaria should be included as a key component of school health programs, the clear ideas and defined approaches required to effectively improve malaria control among school-age children remain unforthcoming [5]. Even a recent Lancet commentary largely echoed prior (unheeded) calls for interventions specifically targeting this age group by reporting more trials which had failed to define a universally applicable intervention, and offering the potential cost of programs and lack of policy support as continuing barriers to progress [3]. However, effective school-based approaches do exist that can positively impact morbidity. Importantly they include elements that are simple and broadly applicable, and will improve health and wellbeing and in doing so increase the capacity of children to learn [1, 7, 8]. Many also have the ability to benefit the broader community beyond the school in the context of malaria.

In a prior review (2020), Macnab described the global impact of malaria on school children, and outlined the principal school-based strategies tried as a way to reduce the adverse effects of infection on the health of children, their ability to attend school and on their long-term academic potential [7]. Such strategies continue to include seasonal chemoprophylaxis, intermittent protective treatment and antimalarial therapy linked to mass drug administration for neglected tropical diseases. This review also emphasized the global need for children to be educated about malaria at school so that they understand how it is caused, how it can be prevented, and the importance of early diagnosis and prompt treatment. This is a fundamental need in addition to being a necessary component that must be provided in parallel with any preventive or therapeutic strategy if it is to be fully effective.

Expanded and innovative strategies are needed to regain momentum over malaria control, including new and better diagnostic approaches to address malaria in children because of the current levels of morbidity and mortality [9]. The WHO estimates widespread deployment of insecticide-treated bed nets, vector control programs, rapid diagnostic testing, new treatments and prophylactic strategies have averted 7·6 million deaths since 2000. But recently stated global targets to reduce case incidence and mortality rates by at least 90% by 2030 are now at risk, and emphasize again that a disproportionate disease burden falls on children [10].

Schools are important in the fight against malaria on several levels. Simple and inexpensive additions to the curriculum can increase children's knowledge and improve their health, and where teachers are engaged and taught the necessary skills schools can provide their pupils with timely diagnosis and treatment. School-based programs that educate children broadly on the causation and prevention of malaria and what care is required, reduce child morbidity. But health promotion in schools is also known to benefit the broader community, as where children receive appropriate guidance they can act as agents for change both within and beyond the school and spread the knowledge they acquire to their families and beyond [3, 11, 12]. This willingness and ability to share learned concepts and practices also indicates that children educated in this way acquire higher levels of health literacy [13].

As early as 2005 Afenyadu et al. proposed improving access to treatment for children with malaria by engaging teachers in care [14]. But the first endorsement of this approach came from the International Pediatric Association (IPA) following a

*Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

2-year trial in rural Uganda of a community participatory intervention model where teachers were taught to screen all sick children using rapid point-of-care diagnostic testing (RDT) and treat those testing positive promptly [15]. The IPA identified this model as applicable worldwide in areas where malaria is endemic, because it significantly reduced morbidity from malaria in school-aged children, and the diagnostic and treatment components were based on the approaches recommended by the World Health organization (WHO) [16].

School-based health care delivery has the potential to benefit more than 1 billion children worldwide [17]. The WHO 'Health Promoting School' (HPS) model is one potential way to initiate school health programs [18]. The model is based on simple concepts and is flexible. The aim is to generate life-long learning through additions to the curriculum that enable children to acquire both relevant health 'knowledge' and practical 'skills' with the overarching objective of positively influencing social determinants of health [19]. Many schools initiate basic health promotion programs independently, others require varying levels of teacher training, resource provision and ongoing support [20]. The WHO now endorses school programs as a way to address specific health challenges worldwide.

Effective engagement of schools in health promotion and care delivery is most readily achieved where policies to do so are in place and practical support is provided [17, 21]. Currently there are calls to improve the overall health of children as a way to promote their learning and enable them to achieve their full potential [7]. This has come about because of the growing recognition that good health at school improves educational outcomes, which in turn builds human capital: "the sum of a population's health, skills knowledge and experience that is central to a country's economic growth" [3]. Importantly, addressing malaria in school-age children is now an element in this goal to build human capital.

There is growing evidence of 'what works and why' in the context of health promotion in school settings. Gaps remain in our understanding of the optimal intervention and programing needed in the context of malaria, and ongoing efforts to conduct research to identify effective programs is essential, and ideally followed by the conduct of randomized controlled trials [7]. Cohee has described school health as "the key to unlocking the potential of the world's children," and that "schools offer a uniquely sustainable platform for health delivery in low resource settings, while at the same time influencing community change through their education role" [3].

Importantly, the literature describes several approaches employed successfully to address malaria in school-aged children, and while many have significant limitations in terms of being broadly applicable, these too may still be the right approach in defined circumstances. New strategies are also being proposed; many are innovative modifications of prior approaches, some are specific refinements to address challenges like emerging drug resistance, and of course the new recommendation for the first malaria vaccine to be rolled out on a large scale now has to be factored into national programs to fight malaria [22, 23]. The aim must be to find broadly applicable, socially acceptable, cost effective, interventions to reduce mortality and morbidity in school children. Such programs in turn will ensure that malaria does not negatively impact the ability of participating children to achieve their academic potential by minimizing the risk of short- and long-term cognitive impairment, and that the broader community becomes better informed about the challenge of malaria and ways to address it, through the 'trickle down' effect of pupils sharing knowledge and skills learned with their families [24]. Where programs successfully reduce the

incidence of infection in children, the broader community also benefits through the overall local reduction in the reservoir of malaria transmission [8].

#### **2. Therapeutic and interventional approaches**

Despite being preventable, detectable and curable, malaria remains one of the main causes of mortality and significant morbidity due to infectious disease [9]. Trialed approaches to reduce morbidity in school-age children include prophylaxis, intermittent protective treatment (IPT), mass drug administration (MDA) and combination of rapid diagnosis and treatment. Preventive treatment to protect school-aged children significantly decreases P. falciparum prevalence, malaria-related anemia, and also the risk of subsequent clinical infection across transmission settings. Hence the logic of policies to make therapeutic intervention strategies broadly available to protect this age group; this approach could also provide benefit by decreasing transmission, and thereby advance the goal of malaria elimination [8].

#### **2.1 Prophylaxis**

In areas where malaria is endemic prophylaxis is generally not recommended for children due to poor adherence to prescribed regimens, limited compliance due to cost, side effects over time, and the risk of emergence and drug resistance [25].

#### **2.2 Intermittent protective treatment (IPT)**

IPT involves periodic drug administration at defined intervals of a full therapeutic dose of a single drug, or drugs in combination, to those at high risk regardless of their infection status. Trials have involved two main approaches, seasonal malaria chemoprevention and intermittent parasite clearance. An example of IPT delivery through schools is described by Fernando et al. from Sri Lanka [26]. In a randomized doubleblind placebo-controlled trial school children aged 6–12 years were given weekly chloroquine or placebo for 9 months. The incidence of malaria fell in the treated group, and a significant difference in absence from school and a marked improvement in school performance was found between them and those pupils receiving a placebo. Evidence from several African countries has shown that seasonal malaria chemoprevention measures can be highly effective, with most severe malaria eradicated, and a reduction in P. falciparum prevalence, the incidence of clinical uncomplicated malaria, and malaria-related anemia [27].

Trials data generally indicate that IPT regimens benefit school-age children by reducing rates of infection, improving health, decreasing absence from school, enhancing academic achievement, and protecting cognitive ability [28, 29]. There is consensus that IPT is a safe and simple strategy that offers remarkable protection in school-aged children in high-malarial-transmission settings, and preferable to prophylaxis. Effective strategies are seen as a potentially valuable addition to school health programs [30]. Evidence from several African countries has also shown that SMC using SP-AQ is highly effective, eradicating most severe malaria, and leading to strong reduction in P. falciparum prevalence, the incidence of clinical uncomplicated malaria, and malaria anemia; two systematic reviews and meta-analyses on efficacy and safety summarize the pros and cons of specific drug regimens [31, 32].

*Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

#### **2.3 Mass drug administration (MDA)**

MDA is a WHO endorsed strategy to control 7 of a group of 13 major, disabling and 'neglected' tropical diseases (NTDs) (ascariasis, trachoma, trichuriasis, hookworm, schistosomiasis, lymphatic filariasis, and onchocerciasis) [33]. MDA has been combined with the delivery of other care entities in school-based settings. In Ghana, combining IPT for malaria with MDA to control intestinal soil-transmitted helminths benefited measures of anemia, sustained attention and recall [34]. And, in Malawi the approach was found to be well-tolerated, safe for teachers to administer, beneficial, and well-received by parents; all findings of obvious practical importance [35]. Adding malaria IPT to already established NTD control programs also increases the cost-effectiveness of both interventions, particularly where teachers are trained to be part of program delivery.

#### **2.4 Combined rapid diagnosis and treatment**

Diagnosis and treatment in combination employs the use of rapid diagnostic test kits (RDT) and treatment of those testing positive with artemisinin combination therapy (ACT). This has primarily been a clinic-based strategy, and is an approach endorsed by the WHO as the first-line of treatment in areas where malaria is endemic [7, 16]. In order to increase access to this standard of care, several countries have reported expanding the role of pharmacists by training them how to do RDTs [36]. Reports have also followed of successful 'downstream' expansion through schoolbased programs where appropriately trained volunteer teachers administer RDT to all children who are sick at school, and administer ACT promptly to those testing positive [15, 37].

RDTs are an inexpensive diagnostic approach, reliably estimate infection in low and high prevalence categories, and have the major advantage that they make immediate treatment feasible [38]. The sensitivity and specificity of RDTs are good enough for them to replace conventional testing for malaria. The positive impact of RDTs on malaria management has been widely demonstrated, and effective roll-out and sustained use on a national scale has been achieved through well planned implementation [39]. Basic training in their use also enables teachers and other providers without a healthcare background to use them reliably [40]. When employed for school-based diagnosis it has been shown that practical aids in the form of step-by-step usage guides can improve performance. Like any technology, refinement will likely be needed over time to keep to keep RDTs a cutting edge diagnostic entity.

ACTs are a unique class of antimalarial drugs. Developed from plant-based peroxides they kill young intraerythrocytic malaria parasites before they can develop into more harmful mature forms; this achieves a robust parasitological response which results in rapid clinical improvement [41]. More than 20 years ago the WHO recommended ACT as the first-line treatment for P. falciparum malaria in all countries with endemic disease [42]. The benefits of genuine ACTs are considerable, and include their fast action, high efficiency, minimal adverse effects, low cost, and the potential to lower the rate at which resistance emerges and spreads [43]. However, care must be taken over the choice of the preparation used, because sub-standard and counterfeit products with little or no efficacy pose severe threats to human health, and there is increasing concern over the emergence of resistance to this class of drugs [44].

Where the efficacy of ACTs is high, more could be achieved through increasing their availability. But in spite of the large body of evidence for both the efficacy and safety of ACTs this drug class is not being used as widely or as comprehensively as it should be [45]. An additional concern is that even when they are available, the way ACTs are used does not always conform to international guidelines [46]. There are of course many practical challenges to making ACTs more available globally, including cost, and finding effective ways to distribute and administer ACTs to a greater number of children, who are arguably the population who needs them most [47]. Continuing to search for innovative ways to increase ACT availability and promote their appropriate use are two essential components for improving malaria control in school-aged children. Approaches to date with promise include: a community case management approach, where a variety of trained providers are used to deliver ACTs [48], distribution through agents in drug stores, pharmacies and private medical clinics [49], and of course via teachers in school health programs [15, 37].

Importantly, the use of RDT and ACT is endorsed by the WHO, and arguably, increasing access to this combined diagnostic and treatment approach is one of the simplest and potentially most cost-effective ways to reduce malaria morbidity among school-aged children. This is especially true in countries that are already using RDT and ACT in government hospitals and clinics, as expansion of bulk purchasing and scale up of distribution offer a more economic proposition than developing new programs which will potentially require other drugs and alternative infrastructure. The use of RDT and ACT in non-traditional outlets is particularly applicable in rural areas where distance limits ready access to hospital and clinic facilities.

#### **2.5 Multiple first line therapies**

Use of multiple first-line therapies (MFT) is an emerging strategy where several ACTs are prescribed together rather than a single first-line ACT. Because antimalarial treatment currently depends so heavily on artemisinins, the evolution of resistance to ACTs in some parts of the world seriously threatens the overall effectiveness of antimalarial treatment [50]. The emergence of resistance is compounded by use of these drugs in some of the poorest countries in the world, where the dosage used is often incorrect, ineffective counterfeit products are widespread, poor quality drugs are commonly purchased due to their lower cost, and a complete course of treatment is not taken as some is held back to use with future illness [44].

The WHO has also identified that the dosage recommendations for a number of antimalarials used in children have not always been optimal. This is largely evident where schedules are derived from adult dosing regimens [46]. This too creates increased selection pressure for the emergence and spread of resistance. However, while there is growing concern that resistance to ACTs could spread rapidly, modeling predicts that using MFT rather than a single first-line ACT will reduce the number of treatment failure in the long term, and prolong the effective life of this important class of drugs [51].

#### **3. School-based community teacher-driven intervention models**

#### **3.1 History**

As early as the 1920's it was recognized that use of malaria suppressive drugs for special groups might be beneficial. Quinine was tried in Ghana (Gold Coast) in 1925 with little success. In the 1950's several school-based trials of the synthetic *Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

antimalarial pyrimethamine were conducted in sub-Saharan Africa; these showed that malaria could be successfully controlled, and treated children were found to have significantly better general health and average weight gain compared to untreated children [7].

In 1955 Colbourne reported using a combination of amodiaquine and pyrimethamine to suppress malaria in 7-year-old children in a school in Accra, Ghana. In the regimen used, children received amodiaquine at the beginning of each term to clear parasitemia followed by pyrimethamine weekly to provide suppression. A control group received comparable placebo. In treated children a 50% reduction in absenteeism resulted; the first use of this measure as a surrogate for morbidity from malaria [52].

#### **3.2 Teacher administered RDT and ACT**

This community participation teacher-driven model was first implemented in 4 low resource communities in Uganda where sick children were usually just sent home for parents to manage, and teachers had identified the burden malaria was taking on the health and academic potential of their pupils [15]. In order to ensure that the resources and will of the community were behind any program implemented, the principles of respectful engagement were followed by engaging in dialog with community leaders, teachers and parents and exploring a range of possible interventions. The plan the community chose as the best, locally achievable approach was for two volunteer teachers in the each of the schools to be trained how to use RDT kits to test for malaria in all the children falling sick at school on a daily basis, and administer ACT promptly to all those testing positive.

In order to evaluate the effect, the schools were taught to formally record their regular daily census of which pupils were present or absent at school, and how to document numeric and descriptive data on the children requiring the planned intervention. The daily census data documenting when and how long any child was absent were then recorded for a full year prior to testing and treatment beginning. During that time a local clinic ran training days to teach all required skills and safety procedures to the teachers [53], orient the schools on data collection, screening and treatment, and set up delivery of the RDT kits and ACT supplies. The same data collection on absenteeism was then continued during the following year; the consecutive 2 year timeline was to ensure no bias from seasonal variations in malarial infection. In addition, the number of children found to be sick each day, tested using RDT, found to be RDT positive for malaria, and who received ACT was documented. A brief clinical history for each child treated also noted the time line for their return to class. A single dose ACT preparation was used to ensure a full course of treatment was completed.

Results: In the pre-intervention (year 1) 953 of 1764 pupils were sent home due to presumed infectious illness. At home, parental management only approached WHO standards for accurate diagnosis and prompt treatment of malaria in 1:4 children, and the mean duration of absence from school was 6.5 school days (SD: 3.17). During school-based teacher-administered RDT/ACT (year 2) 1066 of 1774 pupils were identified as sick, 765 of these had a positive RDT and received ACT, and their duration of absence fell to 0.6 (SD: 0.64) days p < 0.001. Many of the children felt well enough to return to class within hours of being treated; this was presumed due their malaria being diagnosed early in its evolution, and the prompt treatment with ACT being effective.

Overall, absence from school was reduced by 60.8% during this intervention. If the same percentage of children sent home in year one had malaria as were diagnosed using RDTs in year two, this would equate to 1358 cases in 1775 children over the 2 years - a malaria incidence rate of 79% across the 4 schools. The significant decrease in the duration of absence due to malaria from 6.5 school days to <1 day was maintained in the subsequent 3 years when the schools themselves sustained this teacher-driven program. Of interest, these outcome data are directly comparable to Colbourne's initial estimate that 5–6 school days were saved per child with malaria suppression, in her landmark studies 60 years earlier [52]. Importantly, delivery of care using this model was readily implemented and sustained, teachers participated willingly, pupils reported health benefits, and their parents also saw the intervention as positive [7].

A similar approach was successfully trialed subsequently in primary schools in Malawi and was comparably effective. Absence from school was again decreased and the trained teachers were identified to be trusted providers of malaria care [37]. The authors of both studies concluded that training teachers to "test and treat" was well received, supported national health and education policies and was seen to be a worthwhile intervention by the community. Importantly, teachers were enthusiastic about taking part and sustainability was demonstrated by ongoing data from Uganda; the target schools independently continued RDT/ACT post intervention (until the school closures necessitated by the Covid-19 pandemic) and the significant reduction in malaria morbidity (reduction in absenteeism) was sustained; there is also robust evidence of greater knowledge about many aspects of malaria among the schoolchildren and in the broader community.

RDT and ACT are widely employed, but their use by trained teachers in a schoolbased initiative to address the health related consequences of malaria on absenteeism had not previously been implemented. Training teachers is an approach that reflects government policy in many countries to promote RDT use by non-medical personnel [36, 49]. The intervention incorporates diagnostic and treatment entities advocated by WHO [16, 38, 42]. The model is now endorsed by the International Pediatric Association as a community-based approach applicable worldwide where morbidity from malaria is high. Integrating 'test and treat' strategies for malaria control into larger health, nutrition and education platforms that schools can offer, is a pathway that would also help in achieving the current health-related UN sustainable development goals [54].

#### **4. School-based approaches to reduce morbidity**

There are a range of practical measures not directly related to formal additions to the curriculum or the introduction of school-based therapeutic options that can be put in place by school communities to reduce the burden of malaria on their schoolaged children. The most applicable ones are those that individual schools develop themselves in response to local needs that their community identifies, or which grow out of collaborative activities to achieve a defined public health or educational goal. In any given community local needs and resources will differ, so individual initiatives need to be tailored accordingly, and, for instance, accommodate differences between urban and rural settings. Ideally each initiative will be broad and multifaceted enough to leverage as many components of the malaria education/prevention/treatment equation as are required to comprehensively meet the needs of the target school community.

Centering malaria programs on children in schools is an example of the type of innovative, content specific intervention called for by the WHO Commission on

#### *Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

Social Determinants of Health to support health behaviors, and empower young people to take control of their lives [55]. Such 'task shifting' to school-based programs has already increased the delivery of other essential health services for children [23]. Hence, a particularly effective way to develop the measures an individual school or larger community requires, is to use the strategic approaches advocated by the WHO Commission and the Lancet Commission on the future of health in sub-Saharan Africa to improve health literacy and achieve health equity through action [55, 56].

Six of the WHO/Lancet Commission approaches relevant to enabling school communities to reduce the burden of malaria on children are:


#### **4.1 Community empowerment**

There are multiple health benefits to be gained through community empowerment and this approach is needed to promote health in all sections of society [57, 58]. Campaigns that inform, consult, involve, collaborate and empower for example can be used to engage stakeholders in sub-populations at particular risk from malaria. Parents need to be engaged in particular, as care for sick children obviously generally devolves to them. The central problem parents need help with is that many lack the knowledge and/or resources necessary to provide what their child needs when she/ he becomes sick and may have malaria. There is evidence that the current lack of understanding about the approach required to diagnose and treat malaria means that only around 25% of children with early malarial infection receive accurate diagnosis and prompt, effective treatment within 24 hours of the onset of illness, as advocated by WHO [1, 7, 15].

The widespread practice of teachers generally sending home children found to be sick at school compounds this problem, as the end result is that appropriate diagnosis and treatment often do not occur, or at best, the required interventions are delayed [7, 59]. In many communities most febrile illnesses are treated empirically without any diagnostic procedure [44]. Also, dependence on care by traditional healers or trust in prayer often dictates the care a child receives, and there is strong reliance on non-specific medication for fever; preference for such entities contributes to morbidity [60].

Second-order ramifications of malaria morbidity are also compounded in this way. These include loss of schooling due to repeated or prolonged absence, malaise following sub-optimal treatment that prevents full attention and participation in class, and loss of cognitive ability and fine motor skills where a child is left with neurological sequalae. These all negatively impact a child's ability to learn and ultimately rob many of the ability to achieve their long term academic potential [28, 61, 62].

School communities in endemic areas are generally aware of the immediate impact malaria takes on children of school age, but often do not equate infection with impairment of academic performance over time. Parents can be empowered by learning about this association and, in turn, be guided to learn more about the many ways in which they can protect their children against malaria. For example, through the use of insecticide-treated bed nets, indoor spraying, reduction of breeding sites, and other methods for vector control [63, 64].

Communities should be encouraged to see their schools as platforms for the basic education required to inform children adequately about malaria in endemic areas, and be encouraged to lobby for 'test and treat' capacity in schools where the local mindset and/or infrastructure do not make WHO levels of diagnosis and treatment available for children.

#### **4.2 People-centered strategies**

Where low public confidence exists in health care services people-centered strategies can improve low public confidence [56]. Constructive solutions are best arrived at through listening and respectful dialog. What needs to be identified is where the real issues lie, and where distrust is based on misconceptions or misinformation. Practical training in social listening and the use of role-play helps caregivers to respond in a non-judgmental manner.

Where there is a lack of knowledge or practical skills, the best people-centered programs are ones that are flexible, so as to allow the people they are for to get as much benefit from them as their abilities or circumstances allow. If misinformation is an issue, small group discussion will be preferable for many older parents, while internet and social media-generated dissemination of appropriate facts can be used to engage younger segments of the population.

Misinformation on malaria on the internet is not as prevalent as for other health issues such as vaccination or Covid-19 containment. But, it pays to identify and recommend sites with accurate facts and good resources. But, in parallel, reinforce the obvious, that not everything that people read online is true or reliable, and if there are important facts about malaria that anyone does not understand, someone that person trusts should be asked to explain what the key facts are.

Enabling people to understand the importance of controlling malaria and the need to protect children especially is not usually that difficult to achieve. However, strategic planning and dialog are particularly important to ensure understanding over issues that people will see as divisive. An example is the consideration being given to using gene drive approaches as part of future integrated strategies to combat malaria. Gene drive is an advanced form of genetic modification where a lab-created gene is introduced into an organism that targets and removes a specific natural gene. But, importantly this new gene can also automatically replicate itself in a way that ensures virtually all resulting offspring have the lab-created gene. This is in contrast to conventional genetic engineering where only about 50% of offspring are altered. Radical steps of this type are being considered because both the malaria mosquito and the malaria parasite are becoming increasingly resistant to current control methods. Gene drive technology is only authorized for laboratory research at present, but people are already concerned over its potential to impact species other than mosquitoes when it is used in the wild.

*Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

#### **4.3 Innovative education**

School-based programs that educate children broadly on the causation and prevention of malaria, and what care is required can reduce morbidity, and, in particular, increase access to timely diagnosis and treatment. The WHO health promoting school (HPS) model in particular lends itself to education on malaria, as a core concept is teaching children knowledge and practical skills through focused additions to the curriculum [17, 18]. Elements of the HPS model can be applied in various ways to either generate an overarching health ethos in the school or focus on a locally relevant health issue like malaria [18].

Award schemes should be explored as a way to foster HPS activity; a variety of support and recognition strategies can be put in place that will encourage individual schools, and create a spirit of competition between schools that is synergistic [21]. Although not evaluated specifically in the context of malaria education, the experience in African schools following the WHO HPS model is that health promotion activities benefit from local recognition and spread from one school to another through healthy rivalry between neighboring schools [65].

Innovative education can be used to address inequitable distribution of knowledge about malaria and promote understanding about the fundamentals of causation, preventive measures and timely diagnosis and treatment. Data on the use of insecticide-treated bed nets for instance suggest focused school-based education positively impacts their use; the need has also been identified for households to learn to make nets available for use by school-aged children [66]. Health promotion messaging should be tailored to address specific need such as this, and framed so that the message resonates with the age group being targeted. Sometimes non-traditional messengers prove to be particularly effective as communicators, for example, young people are drawn to celebrities endorsing health promotion through music videos and social media are an example [67].

In 2020 the World Economic Forum, UNICEF and the World Food Program announced an innovative approach to helping children achieve their full potential. The aim is to improve their health throughout the first 8000 days of life, and thereby build on current investment focused on improving health during the first 1000 days based on developmental origins of health and disease (DOHaD) science [68]. The mechanism proposed will be the development of integrated school programs that combine strategies that improve the health of school-age children. And the goal, to thereby promote their academic potential, achieve better educational outcomes and build human capital [3].

Clearly the education and school-based management strategies required for malaria will be part of this model in future. Integrated school health packages will be based on experience gained from a variety of successful school-based health interventions, and the expectation is that such integration will lead to synergistic effects where combined aims are met through delivery in a single program. Evidence already available from trials of combined health approaches in schools indicates that benefit will also accrue from shared costs, and the stronger health returns anticipated over programs where individual interventions are delivered alone [8, 69, 70].

Schools should also encourage teachers to create and share innovative educational approaches that engage their pupils. For example, clean-up programs can be initiated where children collect discarded plastic bottles, bags and bottle caps on their way to and from school. This approach is innovative as it provides

evidence-based learning on how these items offer a breeding habitat for mosquito larvae, and an introduction to larval source management; a preventive approach with the dual benefit of reducing the numbers of house-entering mosquitoes and those that bite outdoors [64, 65]. Practical learning approaches like this can be complimented by in-class question and answer sessions, and the generation of visual aids for the classroom wall by the pupils that show other effective prevention practices and key facts about malaria.

#### **4.4 Novel and improved tools**

When the use of RDTs was introduced in community pharmacies this form of testing was not a new tool, but its application in this setting was novel, as was the later expansion of RDT kit use to include teachers in school-based programs [15, 48]. RDT use in both settings resulted in a significant improvement in the reach of this diagnostic tool, as it made testing more readily available and accessible to a larger proportion of the population. In school-based programs RDTs also provided a long called for way to improve care of the school-aged child, by providing an immediate and accurate diagnosis which then allows teachers to treat sick children promptly and with confidence [38].

ACTs continue to be the WHO endorsed first-line therapy in most parts of the world. However, the novel strategy of using multiple first-line therapies rather than a single ACT is a treatment innovation that will help counter emerging resistance to ACTs, and thereby allow this class of drug to remain therapeutically useful as antimalarial drugs for longer [50, 51].

While it is well recognized that the malaria targets for the Millennium Development Goals for 2015 were achieved even though the tools used and the ways in which they were applied were often imperfect [71], it is important that the search continues for better tools for all aspects of malaria control. But in parallel, ways should be explored to expand access to the tools we have that work well, ensure that they are used optimally, and find innovative ways in which they can be modified to meet a new need or counter the very real risk of emergence of drug resistance.

In 2021, the WHO made the historic announcement that a long awaited vaccine for malaria was now recommended for the prevention of P. falciparum malaria in children living in regions with moderate to high transmission [22]. A vaccine against malaria has long been sought, but has proved elusive, in part due to the complexity of the parasite and its numerous immune evasion mechanisms [72]. The RTS,S/AS01 vaccine (RTS,S) is designed to induce antibodies against the sporozoite phase of the lifecycle; this blocks infection of the liver, where the parasite would normally mature and multiply before re-entering the bloodstream to further infect erythrocytes.

RTS,S is the first parasite vaccine to obtain regulatory approval, and there are caveats regarding its current place in malaria control, particularly related to the dosing strategy required, the period of protection provided and partial efficacy, all of which leave room for improvement [73]. Currently the vaccine requires 4 doses from 5 months of age, and for the foreseeable future, vaccinated children will also require some form of chemoprophylaxis in addition, in order to achieve optimum vaccine efficacy. Because of the target age group, programs to immunize will obviously not be school-based [74], but awareness that child vaccination is now an option should be incorporated into school-based health education. This investment will mean that the next generation of young parents will know that this form of prevention is available for their children.

#### *Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

Modifications in dose and schedule have contributed to improved vaccine performance, and further variations may follow [75]. But, as important and historic as vaccine use will be, WHO is calling for the introduction of this novel tool to be used to reinvigorate the fight against malaria in parallel with vaccine rollout programs [22]. This is an important opportunity to respond more effectively than in the past to the repeated calls to scale up and improve malaria control in school-age children [23].

National policies will need to be established and strategies developed to promote local programs that incorporate child vaccination. Creating and implementing the programs required will require both inspired leadership and inter-sectorial collaboration, funding, and support in order for communities to 'buy into' the concept and participate successfully. In addition to the public education and engagement needed regarding the vaccine, clear direction and recommendations are also necessary at the same time on how to deliver and sustain the components of the scaled up malaria control programs for children called for by the WHO to accompany introduction of the vaccine [23].

Meanwhile, several other malaria vaccines with different modes of action are under development. Pre-erythrocytic forms continue to be some of the most promising; pre-erythrocytic agents target antigens from the Plasmodium sporozoite and liver stages when infection is in its earliest stages following inoculation and clinically silent. Induction of antibodies and T cell responses clear sporozoites or block their invasion of hepatocytes [73]. Circumsporozoite protein is a specific target in ongoing research; this is the major antigen on the surface of sporozoites. Various approaches are being applied to develop RTS,S derivatives that improve immunogenicity; recent trials indicate that the R21/MM vaccine appears safe and very immunogenic in African children, and promises high-level efficacy [72].

Novel use of technology can also impact vector control and improve the logistics of delivering supplies needed to test and treat malaria in rural areas. The deployment of drones is an example. Use of this technology in Zanzibar has made it possible to map difficult to find water pools which enables breeding sites to be targeted before larvae turn into adult mosquitoes, and it was learned during the Covid-19 pandemic that drones can be employed effectively to deliver urgently needed supplies when vaccines required in remote areas were provided in this way.

#### **4.5 Training personnel to respond to local needs**

The majority of teachers understand the toll malaria takes on their pupil's health, but many need training to fully understand how they and their school can contribute to strategies to reduce the impact the disease can have on their pupils. For instance, not all recognize that repeated absence from class or a pupil dropping out of school altogether can be due to the cumulative effects of malaria. Also, full realization of the negative impact that severe or repeated infection can have often only comes when the beneficial effects of a school-based diagnostic and treatment program become evident through the school's improved performance in national exams.

It is well documented in the literature that the duration of malaria-related absence, frequency of absence due to repeated infection, residual malaise from sub-optimal treatment and transient neurological complications due to malaria can all compromise a child's potential to learn. In this context, it is important that teachers and parents learn about the negative neurologic effects malaria can cause, and that repeated infection can have detrimental effects that are cumulative, and lead to permanent loss of cognition and learning ability [28, 30, 62]. While the exact mechanisms underlying long-term detriment are debated, a clear relationship exists between the severity of infection and the magnitude of the adverse cognitive effect. An excellent schematic that helps in teaching how adverse effects probably come about and their importance was published in 2010 based on a series of studies examining cognitive function and school performance in children after infection with P. falciparum and P. vivax malaria [62].

Nutrition programs are the most widespread school-based initiatives to promote child health. When personnel are trained to implement them well, such programs can improve children's learning ability and academic potential as well as their physical and mental well-being. Children who are well nourished are better positioned to recover from infectious illnesses, including malaria; significantly it is the most disadvantaged children who often benefit the most from school-based nutrition programs [76]. School garden projects can provide produce for lunch programs to feed children in need. Parents can be trained to collaborate and help run school gardens. A systematic review indicates that multiple life skills are learned and educational benefits accrued by pupils who are actively involved in tending gardens and the growing, harvesting and sale of produce [77].

Teachers in many low and middle income countries have been trained successfully to administer specific health programs in schools in response to identified local needs; examples include: the provision of intermittent anti-malarial therapy in Kenya [25, 78], prophylactic chloroquine in Sri Lanka [26], and nationwide anti-helminth treatment in India, Ghana and Uganda [34, 79]. Tetanus prophylaxis and now vaccination against human papilloma virus are also widely administered by individuals trained to deliver them through schools.

Training of staff in pharmacies to use RDT kits could provide sufficient additional capacity in some communities for this to be an alternative to setting up school-based testing and treatment. Programs developed to train non-medical personnel, including teachers, have been evaluated, and the knowledge and skills such training provides enables practitioners to be both safe and effective [53]. Integrating teachers trained to test and treat for malaria into larger health, nutrition and education platforms offered through schools would likely result in cost-benefit over providing individual health interventions singly, and also deliver combined benefits that would contribute towards achieving the sustainable development goals for health [54].

#### **4.6 Non-traditional avenues and outlets**

To be effective, any intervention that employs a non-traditional outlet or approach must be context-specific and tailored to meet the needs and available resources of the community that will implement and sustain it [3, 23]. The number, variety and scale of the problems communities in low-and-middle-income countries face regarding malaria requires ingenuity and creativity across society to seek out and trial nontraditional solutions that offer potential benefit. School-based health promotion is an example, and interventions with the potential to reduce malaria morbidity in children range from the provision of basic education about malaria through to 'test and treat' programs that implement WHO malaria management criteria.

Schools are still viewed as non-traditional outlets for health delivery, in spite of the many school-based programs that have been shown to provide benefits for the communities they serve. Importantly, evidence of program efficacy includes interventions to reduce the burden of malaria on school-aged children, including ones developed

#### *Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

as a practical response to calls from teachers and community leaders. Unfortunately, not every country has a school system where teachers' morale and motivation make teacher-driven health initiatives feasible [24, 65]. But in the majority, the small number of teachers in each school required to run a 'test and treat' program for malaria are likely to be forthcoming. Certainly, where teachers are aware of the impact malaria has and the improvements intervention can achieve, enough are likely to be willing and able to be taught how to screen children found to be sick at school, treat those testing positive promptly, and refer those children with severe or atypical disease to a conventional health outlet like a clinic or hospital.

From a practical standpoint, community participatory intervention models based in schools are also broadly applicable, and a low cost and flexible approach with considerable potential to meet the longstanding calls for interventions to reduce the burden of disease on school-age children [3, 4, 8]. In addition these models can comply fully with WHO-endorsed diagnostic and treatment principles, follow local government guidelines, and help achieve national goals for malaria control.

Importantly, integration of any avenues that can improve the delivery of health services in a community, or increase access by those needing care will impact the challenge of delay in the treatment of fever [44]. Waiting too long before seeking care for a child likely to have malaria, and failure to obtain an accurate diagnosis and prompt treatment are both major obstacles to achieving the goal of reducing malaria morbidity. Studies indicate that in sub-Saharan Africa <50% of sick, febrile children receive artemisinin combination therapy (ACT) within 24 hours [15, 45, 59, 80]. Approaches that remedy this situation would in themselves go a long way towards reducing the current burden of malaria on children.

#### **5. Conclusion**

Bold decisions are needed to control of malaria and particularly to improve the situation in school-aged children. The longstanding recognition that they are a large and especially vulnerable population has not been matched by clear strategies that can be broadly applied to reduce their burden of disease. School-based interventions to control malaria have obvious logic, as schools allow access to the relevant target population. Suitable initiatives exist that are applicable worldwide and have the potential to benefit millions of children. Education to provide a basic level of health literacy about malaria causation, prevention and management should be a universal component of the school curriculum where the disease is endemic. There is also evidence that school-based health care delivery, such as teacher-driven test and treat programs for malaria, offer a cost effective option alone, and especially if combined with other health interventions.

#### **Acknowledgements**

The delivery and evaluation of key school-based projects described was made possible through support from the Stellenbosch Institute for Advanced Study at Stellenbosch University in South Africa. Funding for the novel teacher-driven 'test and treat' program in Uganda was provided by a grant from the Hillman Medical Education Fund in Canada.

#### **Conflict of interest**

The author declares no conflict of interest.

### **Author details**

Andrew Macnab1,2

1 Faculty of Medicine, University of British Columbia, Vancouver, Canada

2 Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa

\*Address all correspondence to: ajmacnab@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children DOI: http://dx.doi.org/10.5772/intechopen.106469*

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#### **Chapter 8**

## Prevention, Treatment and Malaria Control: A Southern America Perspective

*Carol Yovana Rosero-Galindo, Gloria Isabel Jaramillo-Ramirez, Cesar Garcia-Balaguera and Franco Andres Montenegro-Coral*

#### **Abstract**

Malaria is one of the diseases with the highest morbi-mortality rate worldwide, including Colombia, where it is endemic in several regions of the country. Although the incidence of this disease in the Department of Meta and the Atlantic Coast is not as high as in Nariño, the number of reported cases has held steady over time. It is still an event of great interest in public health. The struggle against malaria is part of one of the Millennium Development Goals and has generated global and national programs that have been implemented at a national and global level, whose main goal is to control and eradicate malaria. These programs have stood out for their vertical nature and for the low level of community participation. Health sector needs to include, at a micro-level, the voices of the community represented in their discourses and actions in the face of the disease, its prevention, and treatment. Therefore, a community and institutional look at these elements, in relation to the disease and the vector, should be provided, which will allow the vector and disease control programs to be improved, designing strategies to bring community and government agencies together to propose public health policies and programs.

**Keywords:** Colombia, community, government agencies, malaria, control programs

#### **1. Introduction**

Malaria remains a global public health problem, with nearly 3.2 billion people in 97 countries at risk of being infected and developing the disease, leading to a high social and economic burden. According to the World Health Organization, malaria cases have increased since 2015, showing a significant increase not only in morbidity but also in mortality in 2020, due in part to the COVID-19 pandemic [1]. Significant progress has been made in malaria control over the past two decades in America, but in recent years, there has been stagnation and an increase in the number of cases in countries such as Venezuela (811.5% between 2010 and 2017) and Nicaragua (1482.2% between 2010 and 2017) [2]. During 2021, 72,022 cases of malaria occurred in Colombia; 70,838 of them were non-complicated malaria, and 1184 were complicated malaria (1.64%). The annual parasite index was 8.93 cases per 1000 inhabitants, with a predominance of *Plasmodium falciparum* (49.6%) and *P. vivax* (49.4%). Mixed infections accounted for only 0.9%. During that year, major outbreaks occurred in 13 municipalities of the country, and the most affected departments where Choco, Nariño, Cordoba, Amazonas, Antioquia, Meta, and Caqueta. 57.8% of the cases occurred in men, and 738 cases were reported in pregnant women [3].

Malaria is a multicausal disease, and therefore, new approaches to control it are comprehensive and include individual, community, and institutional participation to strengthen the capacity of local response to achieve a sustainability of actions with an emphasis on promoting good health and preventing malaria [4]. However, despite existing policies, plans, and programs, malaria remains a serious public health problem in the country. Since the dawn of the twentieth century and during the time of public hygiene, malaria and anemia produced by uncinaria have been considered one of the priorities for control [5]. Between 1956 and 1993, a vertical control program was carried out in Colombia headed by the Ministry of Health's Direct Campaigns Directorate and the Malaria Eradication Service (SEM by its Spanish acronym), a program that ran parallel to the National Health System [6]. During the nineties, profound reforms to the health system were carried out through Law 100 of 1993, which led to the dismantling of the programs headed by the state, transforming the fight against malaria into a control program with several actors involved [7].

Nevertheless, malaria is a disease that is closely related to the level of poverty in a community. It slows economic growth and perpetuates the vicious cycle of poverty. Rural areas are the most vulnerable since buildings and living facilities are deficient and generally have little or no protection against mosquitoes [8].

In Colombia, rural areas reveal concerning levels of health indicators; high levels of malnutrition; low levels of schooling of the population; higher illiteracy rates; and low coverage of basic public utilities, including potable water, sewerage, and electricity. This problem is largely due to the geography, the great distances and topographic difficulties of the terrain that make it difficult to enter certain areas, and also public order issues due to the presence of armed conflict participants and very low or lack of presence of health service providers [9]. These socio-economic factors play an important role in malaria transmission and in other human activities that foster movement of populations, such as migration and wars, leading to the spread of both the parasite and the vector [10].

According to the programs derived from the health system reform, malaria control activities are divided into collective actions (headed by the state) and individual actions (headed by health insurers and health services providers). The following activities are carried out as part of the collective activities included in Collective Interventions Plan (PIC by its Spanish acronym) headed by local authorities, vector control, intra- and peri-domiciliary fumigation, handing out bed nets (mosquito nets), and the supervision of the event by the municipality [11] (National Health Institute, 2014). However, programs are designed without the participation of the communities involved, ignoring local knowledge and socio-political and cultural dynamics surrounding their main health problems, in this case malaria. This leads to imposing out-of-context control measures that reduce the coverage and impact of interventions [12].

Communities forge discourses and knowledge about health and illness that are reflected in attitudes and individual actions that can contribute to the success or failure of the program. Community participation in health programs requires measurable changes in behaviors that allow for active personal involvement in decision-making regarding the health of their own families. Health personnel also have their own views of community affairs from their knowledge, hierarchies, and practices. These discourse and activities draw paths of malaria prevention, treatment, and control, often

#### *Prevention, Treatment and Malaria Control: A Southern America Perspective DOI: http://dx.doi.org/10.5772/intechopen.108921*

parallel to and with no contact between them. This is the reason why the community perspective needs to be incorporated into institutional programs.

In light of the aforementioned, the health sector needs to include, at a micro-level, the voices of the community represented in their discourses and actions in the face of the disease, its prevention, and treatment. It is important to note that the studies carried out so far in Colombia have focused on areas with high endemic rates. Nonetheless, it is important to keep an eye on community and governmental dynamics in areas where the number of cases is not high but has remained constant throughout the years and where outbreaks eventually occur.

#### **2. Epidemiological depiction of malaria in the world and in Colombia**

Malaria, a disease transmitted by mosquitoes of the genus *Anopheles* and produced by parasites of the genus *Plasmodium*, remains a global public health problem, with nearly 3.2 billion people in 97 countries at risk of being infected and developing the disease, leading to a high social and economic burden [13]. Between 2000 and 2020, an estimated 1.7 billion cases and 10.6 million deaths worldwide were estimated, falling from 896,000 in 2000 to 558,000 in 2015. However, there was an increase (627,000) partly due to the COVID-19 pandemic [1].

By 2020, there were 18 endemic countries in the Americas, accounting for 0.3% of the total malaria cases in the world. Brazil, Colombia, and Venezuela accounted for 77% of the cases in the region. In the past 20 years, significant advances have been made in decreasing the incidence in endemic countries, from 14.1 to 4.6 cases per 1000 inhabitants at risk and a 58% reduction in overall cases. Mortality also decreased from 0.8 to 0.3 deaths per 100,000 inhabitants at risk. Despite this, countries such as Venezuela have significantly increased the number of infections, from 35,500 in the year 2000 to more than 467,000 in 2019, affecting the statistics in the region. Other countries such as Bolivia, Haiti, Honduras, Nicaragua, and Panama showed substantial increases in 2020 in comparison to 2019 [1].

In Colombia, malaria is present in more than 80% of the national territory, with five macro-foci of variable and active transmission: the Pacific Region (departments of Choco, Nariño, and Cauca and the district of Buenaventura in Valle del Cauca), the Amazone-Orinoquia Region (departments of Amazonas, Vichada, Guainia, and Guaviare), Magdalena Medio (Antioquia, Bolivar, and Cordoba), and a recent focus on the border with Venezuela (department of Norte de Santander) [14]. Thanks to its extensive and diverse social and environmental conditions that have led to the transmission and endemicity of this disease in the country [15], malaria still represents a serious public health issue.

During the year 2015, 56,705 malaria cases were reported in the system in Colombia. 55,866 were cases of non-complicated malaria, and 839 were cases of complicated malaria. 18 deaths from this disease were reported. Choco, Nariño, and Antioquia headed the list of reports, accumulating more than 75% of total cases in the country [16]. By 2016, the increase in cases was evident, with 84,742 reports, of which 83,227 were non-complicated malaria and 1515 were complicated malaria. Additionally, 26 confirmed deaths and 10 deaths classified as compatible cases were reported [17]. During 2017, the decline in cases was evident, with a total of 55,117 reports across the country. The departments of Choco, Nariño, Antioquia, Cordoba, Guainia, Amazonas, Cauca, and Vichada registered 90.7% of cases of non-complicated malaria [18]. For the year 2018, there was a 14.6% increase compared to the previous year, with a total of

63,143 reported cases of malaria in the country. 54% of the cases came from the Pacific region, with the department of Choco (27.7%) being the largest reporter of cases, followed by the department of Nariño, with 21.8% [19]. For the year 2019, there was a situation of sustained malaria outbreak throughout the year, with a total of 80,415 cases reported in the system, of which 79,120 (98.3%) were classified as non-complicated malaria and 1295 (1.6%) were classified as complicated malaria [20]. Similar numbers were observed during 2020, with a total of 80,236 malaria reports in the public health monitoring system. Despite the health emergency caused by COVID-19 and the mandatory preventive isolation that occurred in the country from epidemiological week 12 to week 32, the country was hit by a malaria outbreak situation from epidemiological week 18 to week 23 and then from week 30 to week 53. Historically, Choco, Nariño, and Antioquia remain the departments with the highest incidence of the disease [14]. The year 2021 showed a decrease of 11.4% with respect to the previous year, with a total of 70,838 cases reported. 14 municipalities reported outbreak situations. During this year, 1291 cases of coinfection between malaria and COVID-19 were reported [14].

#### **3. Community-based knowledge and actions regarding malaria**

From a cultural perspective, the health system is made up of hierarchies or levels: the popular, the folkloric, and the professional level. An approximation among the three represents pluralism in the healthcare of a particular social group [21].

The so-called third sector, or professionals, has a technical language that separates it from their patients—their own body of knowledge. It emphasizes on the disease and is often based on technology. This perspective applies both to health care and to the generation of policies, plans, and programs that are vertically established, ignoring the conception of local medicine, which is part of a larger system of beliefs, behaviors, and attitudes.

It is important to emphasize that part of the verticality with which most health programs are established originates from this hierarchical sectoring specific to the area's staff. Knowledge and training, different from those of the community, create a gap that separates them. The community that "does not know" can be diagnosed and treated because its cultural baggage is not recognized as it is another type. In addition, this alleged "superiority" leads to a paternalistic treatment, a position generally adopted in relation to vulnerable communities.

These views of what the community is, from a professional perspective, draw disease prevention, treatment, and control paths, which are often parallel and have no contact between them. Thus, the community perspective needs to be incorporated into institutional programs. Programs are designed with no participation from the communities involved, ignoring local knowledge and the socio-political and cultural dynamics around their main health problems, in this case malaria. This leads to imposing out-ofcontext control measures that reduce the coverage and impact of interventions [12].

#### **4. Malaria control programs in America**

Because malaria transmission is highly heterogeneous, control programs in the Americas have to adapt to these different environments [22]. Reactive strategies are the most feasible ones and are endorsed by the World Health Organization [23]. Reactive case detection (RACD) tests and treats all household members related with a positive

malaria case detected in a health facility; sometimes the neighbors are also treated [24]. Other strategies try to test the whole community that has at least one diagnosed case; this strategy is called mass screen and treat (MSAT). Or they test the whole population even if there is not a confirmed case of malaria, called mass test and treat (MTAT) [25]. The best strategy depends on the resources and their objectives, and these activities have to be attached to an effective vector control program and a strong health system [26].

#### **5. Malaria control programs in Colombia**

Since the dawn of the twentieth century and during the time of public hygiene, malaria as well as anemia produced by uncinaria have been considered disease control priorities, because they affected those areas where the production of coffee and oil began to be fundamental to the economy of the country [4].

The public health programs that marked the beginning of the twentieth century were designed from the perspective of the control and power that dominated the context of the new century. Europe was uniting at the expense of great wars, and the eyes of the great powers turned to Latin America's resources for the reconstruction of their economies. International health agencies were born in response to the need to control the prevailing tropical diseases in which North American companies began to reap benefits from the newly discovered products, channeling the expansion of the exchange in the Americas under civilizing, modernizing, and hygenizing slogans [27].

Between 1956 and 1983, a vertical control program was carried out in the country headed by the Ministry of Health's Direct Campaigns Directorate and the Malaria Eradication Service (SEM by its Spanish acronym), a program that ran parallel to the National Health System [5], and it stood out for its warmongering conception of the disease with a marked use of military terminology [28].

This period was marked by the implementation of the strategy of the Pan-American Health Organization (now known as PAHO), which in the face of communicable diseases such as yellow fever and malaria focused its activities on eradicating the vector and, consequently, the disease, introducing the use of residual-acting insecticides (DDT: dichloro-diphenyl-trichloroethane), which were initially used as pediculicide against a typhus epidemic in Naples between 1943 and 1944. The objective of the campaign was to achieve the eradication of malaria throughout the national territory, and it was carried out in four phases: preparatory, attack, consolidation, and maintenance phases [27].

During the 1980s and 1990s, there were profound reforms to the health system. Between 1983 and 1990 and in line with the State decentralization reforms, the program went from being run by the nation to the being run by the departments [29]. Between 1991 and 1994 and specifically after Law 100 of 1993, the programs run by the State ended, transforming the fight against malaria into a control program with several stakeholders dividing malaria control activities into collective actions (headed by the State) and individual actions (headed by health insurers) [7].

From the market perspective of the health system in force since 1993 and with the corresponding loss of control on the part of the state, malaria management programs have deteriorated due to the fragmentation of actions, leading to the loss of information due to the lack of robust data-gathering and analysis systems, the dismantling of the diagnostic capability installed, and the deterioration of the indicators of disease control [6]. During 2010–2015, the "Malaria Project" was carried out, with the general purpose of reducing malaria morbidity and mortality in the departments, with

the highest concentration of cases in Colombia. The objectives were aimed at designing and implementing communication and social mobilization plans to increase protective factors [30]. However, none of the departments involved in our study were within the Malaria Project action plans.

#### **6. Malaria control, prevention, treatment, and access issues in rural communities**

Diseases such as malaria mainly affect populations under poor socio-economic conditions, living in precarious housing, with limited access to basic public utilities such as potable water and basic sanitation; under deteriorated environmental conditions; and with barriers to access health services. Other human activities that foster population movements, such as migration and wars, lead to the spread of both the parasite and the vector. Generally, these vulnerable populations live in rural or peri-urban areas [16]. High prevalence of this disease diminishes economic growth and perpetuates the vicious cycle of poverty. Rural areas are the most vulnerable since buildings and poor housing facilities have very little or no protection against mosquitoes [8, 10]. In Panamá, malaria cases have progressively increased in prevalence in the past 20 years. Factors such as a weak control program have affected the indigenous settlements in a major proportion [31].

In Colombia, housing conditions and basic needs are very variable; in the Olaya Herrera municipality (Pacific region), only 33.6% of the population has aqueduct, 8.2% has sewerage, and 65% has garbage collection [32]. In Vista Hermosa (a hilly landscape and alluvial plains area of the eastern plains), electrical services coverage is only 89%, and the garbage collection service reaches 85%. A similar percentage of coverage is found in the aqueduct and sewerage services, reported only by 78% of the inhabitants. Similar conditions are evident in San Jose del Guaviare (transition area between the Orinoquia and Amazon regions), where the water supply service reaches only 60% of these communities and the sewerage service reaches 53.4%. Likewise, garbage collection reaches 87.4%. Overall, these conditions have led to a significant deterioration of environmental conditions, and the population's low awareness of these issues adds to these issues. In many areas of the municipalities, garbage can be seen on the streets and water source contamination is very evident.

Child mortality from malaria could be reduced by up to 20% if people were to sleep under insecticide-treated (mosquito) bed nets. Fast access to effective treatment can further reduce deaths. Intermittent preventive malaria treatment during pregnancy can significantly reduce the proportion of low-birth-weight babies and maternal anemia [8].

In Colombia, the provision of health services in dispersed rural areas is hampered due to the geographical isolation of many communities; distances and topographic difficulties of the terrain make entering these areas difficult. Public order issues due to the presence of participants of the armed conflict do not allow the approach and adequate provision of health services. In remote rural areas of the country, quality of life indicators lag behind. There are reports of high fertility; high infant and maternal mortality rates; low life expectancy; high levels of malnutrition; low levels of schooling; high illiteracy rates; and low levels of basic sanitation services coverage for potable water, sewerage, and electricity in the population. On the other hand, ethnic groups with different cultures, knowledge, and activities related to health issues, with a greater emphasis on the ancestral medicine of their communities, predominate in these areas, which poses a challenge to their healthcare [9].

#### **7. Knowledge, attitudes, practices, and intervention related to malaria in Colombia**

Since it is one of the most malaria endemic areas, several studies have been carried out in the Pacific to implement and evaluate strategies to improve the quality of life there, starting with the reduction of malaria cases in communities. Educational strategies can improve prevention practices in communities, and this is reflected in the decrease in the incidence of malaria cases in the areas under intervention [33]. In addition, the inclusion of educational strategies integrated in national control program activities leads to a decrease in institutional costs and a reduction in cases [34].

In the municipality of Bahia Solano, it was discovered that more than 70% of the people surveyed know that malaria is transmitted by a mosquito bite. However, about 55% do not go to a health center for treatment but take herbal infusions or baths prepared with plants [35]. In the municipality of Olaya Herrera, 61% of the people surveyed claimed to have contracted malaria, and 75.37% considered the disease a problem for them and their families [32].

In the eastern plains, in the municipality of Vista Hermosa, 43% of respondents reported having had malaria at some point in their lives, and 90% still consider this disease a problem for themselves and their families. In terms of knowledge about the disease, 63% recognized that a mosquito is the vector of malaria, although they did not specifically identify which mosquito it is. In the municipality of San Jose de Guaviare, 59% of respondents said that they had malaria at some point in their lives, and 16.5% do not consider malaria a health problem for themselves and their families. 76% knew that the disease is transmitted by any mosquito bite, and only 6% knew that the Anopheles mosquito was specifically the vector of this pathology.

Despite growing community awareness of the way in which the disease is transmitted, they have no confidence in care centers. 38.7% of respondents said that they did not receive good care from health officials when they were suffering from malaria, while 90.98% of those who had malaria went to health centers and followed the treatments prescribed by doctors. 43% claimed that the office of the secretary of health makes no effort to reduce malaria in the municipality, and 51% said that there is no malaria awareness education [32]. In Vista Hermosa, most of the disease control actions are individual, among which are the drainage of lagoons and ponds at 32% and the use of bed nets (mosquito nets) at 74%. None of the respondents reported using household awnings to prevent mosquito entry, only 9% said they sprayed their homes with insecticides, and 10% used repellents.

It is possible that disconnection between communities and government agencies may be influencing malaria control programs so that they are not very ineffective.

#### **Author details**

Carol Yovana Rosero-Galindo1 \*, Gloria Isabel Jaramillo-Ramirez<sup>2</sup> , Cesar Garcia-Balaguera2 and Franco Andres Montenegro-Coral1

1 Medicine Faculty, Cooperativa de Colombia University, Pasto-Nariño, Colombia

2 Medicine Faculty, Cooperativa de Colombia University, Villavicencio-Meta, Colombia

\*Address all correspondence to: carol.roserog@campusucc.edu.co

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Prevention, Treatment and Malaria Control: A Southern America Perspective DOI: http://dx.doi.org/10.5772/intechopen.108921*

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