Prevalence and pattern of malaria parasitaemia among under-five febrile children attending paediatric out-patient clinic at UMTH, Maiduguri

Niger J Paed 2015; 42 (4): 319 - 324

ORIGINAL

Elechi HA

Prevalence and pattern of malaria

Rabasa AI

Muhammad FB

parasitaemia among under-five

Garba MA

febrile children attending paediatric

Abubakar GF

out-patient clinic at University of

Umoru MA

Maiduguri Teaching Hospital,

Maiduguri

DOI:http://dx.doi.org/10.4314/njp.v42i4.7

Accepted: 7th August 2015

Abstract : Background : Malaria

P. falciparum was seen in all the

has remained a major public

positive slides. The parasite den-

Elechi HA

(

)

health problem in Nigeria with the

sity was generally low with 48.3%

Rabasa AI

under-five aged children and

having parasite densities below

Muhammad FB

Garba MA

pregnant women being the most

100/ μ l and only 7.5% had parasite

Abubakar GF

affected. The local epidemiologi-

density of ≥1000/ μ l. Parasite den-

Umoru MA

cal profile of the disease is dy-

sity increased significantly with

Department of Paediatrics,

namic owing to the continuous

increasing age (p=0041). Nutri-

University of Maiduguri Teaching

variation in the various determi-

tional status as well as other stud-

Hospital, Maiduguri, Nigeria.

nants and hence the need for peri-

ied factors had no significant effect

Email: h2elechi@gmail.com

odic re-evaluation. We aim to

on parasite density (p>0.05).

determine the prevalence of ma-

Conclusion and Recommendation :

lariaparasitaemia among the under

Prevalence of malaria infection

-five aged children and the effect

was high in the population studied.

of various determinants.

It is characterized by low density

Material and Method : In this

parasitaemia and hence the need to

cross-sectional study, 433 out-

interpret negative results with cau-

patients aged below 5 years with

tion. Age, gender, socio-economic

fever or history of fever in the

and nutritional status, temperature

previous 72hours were enrolled.

at presentation as well as owner-

Relevant information was ob-

ship of ITN had no significant ef-

tained and recorded using a ques-

fect on prevalence of malaria para-

tionnaire. Thick and thin films

sitaemia.

There

need

were prepared from a finger or

strengthen and scale up various

heel prick for each of the patients

malaria control programs while

and subjected to microscopy.

ensuring proper implementations

Result : The prevalence of malaria

of programs and activities through

parasitaemia was 27.7%. Age,

effective monitoring and evalua-

sex,

nutritional status, socio-

tion.

economic class, temperature at

presentation as well as ownership

Key words: Prevalence, pattern,

of insecticide treated nets had no

Malaria, Parasitaemia, under-five

significant effect on the preva-

febrile children, outpatient clinic.

lence of malaria (p>0.05). Only

Introduction

and DR Congo; Nigeria and DR Congo accounted for

40% of estimated death globally . More than 80% of

Malaria imposes great socio-economic burden on hu-

these deaths are known to occur in children younger

than five years of age in Sub-Saharan Africa .

manity, and with diarrhoea, HIV/AIDS, tuberculosis,

measles, hepatitis B and pneumonia account for 85 per

cent of global infectious diseases burden. According to

Several studies have been reported from the various re-

gions of Nigeria

4-8

and beyond

9,10

the World Malaria Report released by the World Health

(Ghana and Eretria)

Organization (WHO) in 2012, there were 219 (154-289)

with varying epidemiologic profile for malaria in the

million estimated cases of malaria in 2010 worldwide

under-five febrile children. However, there is dearth of

accounting for 660(610 – 971) thousand deaths. While

information from the northeastern region. According to

40%of the estimated cases occurred in India, Nigeria

the Nigeria Demographic and Health survey of 2008, the

320

Northeastern region had the second highest prevalence

Study Design

of malaria among the under-five aged group . This as-

sertion however, was based on history of fever (proxy

The study was a hospital based cross sectional observa-

for malaria) two weeks preceding the study with no

tional study.

form of parasitological confirmation.It is a common

knowledge that the symptom complex of malaria over-

Study Population and sampling method

laps with those of many other tropical diseases

and

thus may not represent the accurate epidemiologic pro-

Under-five febrile children attending the Paediatric gen-

file of malaria. In addition, with various control meas-

eral outpatient (PGOP) unit of UMTH were eligible to

ures being implemented by several agencies, the preva-

participate after meeting the inclusion criteria. The phy-

lence of the disease is likely to be dynamic and hence

sicians at the GPOP unit were educated on the inclusion

the actual epidemiologic profile may not be known after

and exclusion criteria and eligible patients were referred

an interval of few years.

to the author after consultation for enrollment. Conven-

ient sampling method was employed and patients were

The burden of malaria in communities and countries

recruited consecutively after fulfilling the inclusion cri-

reflect intrinsic and extrinsic determinants. Host immu-

teria. Calculated minimum sample size was 377 using

Taylor’s formula and value of ‘p’ was taken from the

nity, an intrinsic factor, is age dependent in a malaria

study of Ikeh et al from Jos, Nigeria who reported

stable country like Nigeria. In such areas, the under-five

age group is the most vulnerable to malaria infection .

prevalence of 56.9%.

Clinical malaria in them has been shown to be associ-

ated with very low parasite densities . The burden of

Inclusion Criteria

malaria is greatest among the world’s poorest countries

with only 0.2% of global malaria deaths found in the

1. Age of 0-59 months

world’s richest population quintile.

Nutrition plays a

2. Fever (axillary temperature > 37.5°C), and/or history

major role in maintaining health, and malnutrition ap-

of fever in the 72 hours prior to presentation.

pears to generate vulnerability to a wide variety of dis-

Informed consent.

eases and general ill health including malaria

16,17

. How-

ever, there are conflicting report regarding how under-

Exclusion Criteria

nutrition affects susceptibility to malarial morbidity and

mortality. Several studies in malaria endemic regions of

1 . Children on antimalarial treatment or prophylaxis

the world have documented average reduction of 20% in

prior to presentation.

all causes of mortality in children under five years old

within two years of increasing insecticide treated nets

Ethical Considerations

(ITN) use from 0 to 50-70%

18,19

Approval was sought from and granted by the Research

This study thus aims to determine the prevalence of ma-

and Ethical committee of UMTH. Signed or thumb-

laria parasitaemia among under-five febrile children

printed informed consent was obtained from each par-

seeking treatment at the paediatric out-patient unit of the

ent/guardian with unlimited liberty to deny consent or

University of Maiduguri Teaching Hospital (UMTH). It

opt out of the study at any stage without any negative

also determines the associated factors and pattern of

consequence. Information and results obtained were kept

malaria parasitaemia among this age group.

confidential. Results of the tests were disclosed to the

guardians and those with positive malaria parasitaemia

were given antimalarial (Artemether/lumefantrine tab-

Subjects and method

lets 20mg/120mg) free of charge at the expense of the

Study Area

researchers.

The study was carried out at the paediatric general out-

Study Procedure

patient (PGOP) unit of UMTH, Maiduguri, Borno State

The study was carried out from 5 August to 20 Octo-

of Nigeria. Maiduguri, the capital of Borno State is lo-

cated in the northeastern part of Nigeria. It is a semi-arid

ber 2011. On the day of inclusion, demographic and

zone lying between lat. 11.5 N and long. 13.5 E with a

clinical information were recorded using a question-

sunny weather and a temperature that may be as high as

naire. Weight was measured using a digital bathroom

45 C especially in the hot dry season and an annual rain-

weighing machine (Salter Glass Electronic Bathroom

fall of 1.14 mm to 771.90 mm . University of

Scale) in kilogram to two decimal places and for chil-

Maiduguri Teaching Hospital is a centre of excellence

dren who could not stand, the caregiver was weighed

for infectious diseases and immunology. It serves as a

alone and then with the child and the difference of the

referral centre not only for the six states in the region

two was taken as the child’s weight. Length was meas-

(Adamawa, Bauchi, Borno, Gombe, Taraba, and Yobe)

ured using a tape meter on a hard cardboard surface to

but also for the neighboring countries of Cameroun,

the nearest centimetres. Axillary temperature was meas-

ured using a digital thermometer (JOYCARE )in centi-

Chad and Niger. The Paediatric General Outpatient unit

is a busy clinic with an average population of 100-150

grade to one decimal place. Socioeconomic status was

patients per day.

determined from parental education and occupations

321

using the model by Ogunlesi et al . A score of 1-5 was

Results

awarded for each of education and occupation of both

Socio-demographic and Clinical Features

parents separately and the mean of these four scores to

the nearest whole number was the socioeconomic status

A total of 433 children were studied. There were 238

(I, II, II, IV and V) assigned to the child. Classes I and II

(55%) males and 195 (45%) females M:Fratio 1.2:1. The

belong to upper class, while Class III and classes IV and

mean age of the studied population was 19.2 ± 14.3

V belonged to the middle and lower socioeconomic

months. Approximately half of the children studied, 203

classes, respectively. Nutritional status was assessed

(46.9%), were aged 12 months and below. The least

using the Z-score system in accordance with the Na-

frequency was observed among the 49 months and

tional Center for Health Statistics (NCHS)/WHO refer-

above age category, 18 (4.2%) (Table 1).

population. A

ence

weight-for-agez-score

(WAZ),

height-for-age z-score (HAZ) and weight-for-height z-

Table 1: Age and Sex distribution of the study population

score (WHZ) of ≥ -2 was classified as normal and Z ˂ -2

Age Group

Sex

Total

as under-nutrition. Under nutrition was further sub clas-

(Months)

Male

Female

n (%)

sified into moderate under nutrition when WAZ, WHZ

n (%)

or HAZ is between -2 and -3 and as severe when < -3.

0 - 12

118 (27.3)

85 (19.6)

203 (46.9)

Ownership of ITN was used as a proxy for usage due to

13 – 24

66 (15.2)

55 (12.7)

121 (27.9)

the inherent difficulty in assessing actual usage in a

community with no prior standardized instructions on

25 – 36

25 (5.8)

31 (7.2)

56 (12.9)

usage and care of ITN. Thick and thin blood smears

37 - 48

21 (4.9)

14 (3.2)

35 (8.1)

were prepared from a capillary blood sample. Number

49 - 59

8 (1.9)

10 (2.3)

18 (4.2)

was allotted to every participant at the point of entry and

Total (%)

238 (55)

195 (45)

433(100)

was used for identification of slides and questionnaire

from the same patient. The thin blood smears were fixed

One hundred and sixty eight (38.8%) of the studied

with methanol and the thick smears were left unfixed.

population had fever at presentation with axillary tem-

Each slide was subsequently stained with 10% Giemsa

perature ranging between 37.6 and 40.1°C, while 265

solution and left for ten minutes. All blood smears were

(61.2%) had history of fever within the preceding 72

examined microscopically under x100 oil immersion.

hours. The mean, median and mode of the axillary tem-

The thick smears were used for diagnosis of Plasmo-

perature of the studied population were 37.2°C, 37°C

dium specie and for parasite-density counting. Smears

and 38°C respectively.

were considered negative if no parasites were seen in

Majority, 377 (77.8%), of the studied population were of

100 oil-immersion fields. For positive smears, the num-

low socioeconomic status. The remaining 77 (17.8%)

ber of parasites was counted against 200 white blood

and 19 (4.4%) of them belonged to the middle and upper

cells (WBC). Parasite density was calculated assuming

socioeconomic classes respectively. This is due to the

8,000 WBC per microlitre using the formula:

fact that majority of the parents did not go beyond sec-

Parasite density = Number of parasites counted ×8000

ondary education (62.2% of the fathers and 81.1% of the

mothers) and therefore are low income earners.

Number of leukocytes counted

Greater than a third, 164 (37.9%), were underweight

The thin smears were examined to confirm the parasite

while 123 (28.4%) of them were stunted. Among the

species for positive samples. All slides were double-

under-nourished children, moderate under-nutrition (-2

read, blinded, by the 6 author, a qualified and experi-

>WAZ,WHZ or HAZ ≥ -3) was more frequent than se-

enced microscopistfrom the Department of Parasitology

vere under-nutrition (WAZ, WHZ or HAZ < -3) ac-

UMTH and the lead author, who was retrained and certi-

counting for 60%, 64% and 55% of under-nutrition for

fied by a parasitologist prior to commencement of the

WAZ, WHZ and HAZ respectively.

study, with an agreement of >95% between the lead

Three hundred and seven (70.9%) of the children studied

author and the microscopist in slide reading. The slides

owned insecticide treated net while 126 (29.1%) did not.

with discordant findings were resolved through discus-

Sixty five (51.6%) of those who did not own ITN prac-

sion and re-examination of such slide by the both au-

ticed other forms of vector control.

thors at the same time with consensus reached on each

case.

Prevalence and Pattern of Malaria Parasitaemia

Data obtained were entered into a computer to generate

The prevalence of malaria parasitaemia in this study was

a data base. Analysis was done using SPSS version 16.0

27.7%. The effect of different variables on the preva-

(SPSS, Chicago, ILL, USA). Baseline characteristics

lence of malaria parasitaemia in the study population is

(demographic, clinical, and parasitological) were ana-

given in table 3. The age-group specific prevalence for

lyzed using descriptive statistics; mean, mode, medians,

malaria parasitaemia were 26.6, 27.0, 27.3, 27.8 and

standard deviation, as appropriate. Results were pre-

44.4% for 0-12, 13-24, 25-36, 37-48, and 49-59 months,

sented in tables. Frequencies and proportions were com-

respectively. Although, slight differences were observed

pared using Chi-square(x ), strength of association were

in the age group specific prevalence of malaria parasi-

tested using Contingency Coefficient. A 95% confi-

taemia in this study, this difference was not statistically

significant ( x = 2.680, p=0.611). There was slightly

dence interval (95% CI) and a p-value of < 0.05 was

considered significant.

higher preponderance of malaria parasitaemia among

322

males (29.8%) compared to female (25.1%), this differ-

positive correlation was found between age and parasite

ence was, however, not statistically significant ( x =

density (C=0.344, p=0.041). Sex, socio-economic and

1.184, p = 0.277). The Lower SEC class recorded the

nutritional status, ownership of ITN and temperature at

highest prevalence of 41% malaria parasitaemia. The

presentation had no statistically significant effect on

middle SEC had the least prevalence of 19.5% while the

parasite densities in this study (Table 3).

upper SEC recorded 36.8%. However, this difference

( X = 1.417,

was

not

statistically

significant

Table 3: Parasite density by various variables among the study

0.234).The prevalence of malaria parasitaemia was

population

higher among the under-nourished children across the

Variables

Parasite density

three measured anthropometric indices (table 2). How-

<100/µl

100-

≥1000/

x 2

p-value

999/µl

µl

ever, these differences were not statistically significant

( x = 1.014, 2.597 and 0.868, for WAZ, WHZ and HAZ

Age groups(months)

respectively, p>0.05).Ownership of ITN was associated

0-12

15.26

0.004*

with higher prevalence of 29.5% when compared to

13-36

prevalence of 23.4% among those without ITN. But this

37-59

Sex

difference was not statistically significant (x = 1.659, p

Male

2.286

0.319

= 0.198). Febrile children at presentation had slightly

Female

higher prevalence (40.0%) of malaria parasitaemia when

Socio-economic status

compared to those without fever (37.3%). However this

Upper & Middle

2.471

0.291

Lower

difference was not statistically significant (x =0.101,

Nutritional status

and p = 0.751).

Weight for age

Underweight

1.251

0.535

Table 2: Prevalence of malaria parasitaemia by various

Normal

variables in the study population

Weight for height

Wasted

5.672

0.059

Microscopy

Normal

Variables

Positive

Nega

Total

Preva-

P-value

Height for age

tive

lence

Stunted

0.024

0.988

Age groups(Months)

Normal

0 – 12

149

203

26.6%

2.680

0.611

Temperature at presentation

Fever

0.525

0.769

13 – 24

121

27.0%

No Fever

25 – 36

27.3%

37 – 48

27.8%

*, statistically significant P < 0.05

49 -59

44.4%

Sex

Male

167

238

29.8%

1.184

0.277

Female

146

195

25.1%

Discussion

Socio-economic status

Upper

36.8%

1.417

0.234

The prevalence of malaria parasitaemia of 27.7% in this

Middle

19.5%

study suggests that malaria remains a major cause of

Lower

239

337

41.0%

morbidity among the under-five aged group in

Nutritional status

Maiduguri and environs despite several control meas-

Weight for age :

164

30.5%

1.014

0.314

ures. The observed prevalence is similar to 26%reported

by Ben-Edet et al from Lagos and 27-29.5% by Ikeh et

Underweight

Normal

269

26.0%

al from Jos, Nigeria. However, other studies have found

Weight for height:

151

32.5%

2.597

0.107

Wasted

higher prevalences. While this study and the two oth-

ers

6,8

Normal

282

24.7%

with similar estimates were tertiary hospital based,

Height for age:

123

30.1%

0.868

0.352

the other studies with relatively higher figures were con-

Stunted

ducted in PHC facilities , secondary facilities or com-

Normal

310

26.5%

munity based studies. This is not surprising as the lower

Ownership of ITN

Yes

215

305

29.5%

1.659

0.198

cadre health facilities are the first point of contact, while

128

23.4%

the tertiary facilities being referral centers may be seeing

Temperature at presentation

patients who might have had previous treatment includ-

Febrile

120

168

40.0%

0.101

0.751

ing antimalarials

No Fever

193

265

37.3%

Pattern of Parasite Density

Although age is an important determinant of malaria

parasitaemia in malaria stable area, the prevalence of

Plasmodium falciparum was the only specie detected in

malaria infection in this study did not differ significantly

all the 120 malaria positive cases. The parasite density

between the age groups. This finding may not be sur-

was generally low in this study. Fifty eight (48.3%) of

prising as comparison was within the under-five age

the positive patients had parasite densities of <100/µl of

group who are known to share the same immunological

features regarding immunity to malaria. This is similar

blood, while only 9 (7.5%) patients had density of 1000/

µl and above. Age was the only variable significantly

to the findings of Akinbo et al in 2009 from Benin City,

Nigeria. Other studies comparing under-five children

associated with parasite density (x = 15.26, p = 0.004).

Using contingency coefficient (c) a significant but weak

with older children and adults have consistently shown

323

higher prevalence of malaria parasitaemia among the

Contrary to well established positive impact of ITN on

under-five group . However, Ikeh and Teclaire in 2008

4,5

prevalence of malaria

18,19

ownership of ITN had no sig-

reporting from Jos, Nigeria found significant difference

nificant effect on the prevalence of malaria parasitaemia

in prevalence of malaria parasitaemia within the under-

in this study. Similar finding has been reported by other

workers . This finding may be attributed to several fac-

five age group. The reason for the difference in finding

is not clear. On the other hand, parasite density in-

tors; in the first place, ownership of ITN is not synony-

creased significantly with increasing age. In malaria

mous with usage, and even when used, lack of care for

the nets may have contributed to this observation . In

stable area like Nigeria, most children experience their

first malaria infections during the first year or two of

addition, the present study did not evaluate usage of and

life . It is known that the pyrogenic threshold of para-

care for ITNs. Furthermore, those who did not own

site density in a malaria naïve individual increases with

ITNs were not good controls because many (51.6%) of

increasing numbers of clinical episodes of malaria until

them practiced other forms of vector control measures

premunition is attained . Hence the observed relation-

such as usage of insect repellent (mosquito coils) and

ship between age and parasite density in this study.

insecticide which are known effective control meas-

ures .

Similarly, this study and several other studies

5,7,8,

have

observed no significant effect of gender on prevalence

and density of malaria parasitaemiain the under-five

Temperature at presentation neither had significant ef-

children.

fect on the prevalence of malaria parasitaemia nor para-

site density in this study. This finding may be due to the

Malaria is frequently referred to as a disease of the poor

paroxysmal nature of malarial fever and thus history of

or a disease of Poverty. In this study however, socio-

fever may be as important as fever at presentation in the

economic status did not have significant effect on the

clinical diagnosis of malaria. However, while this find-

ing is similar to the finding in other studies

32,33

prevalence and density of malaria parasitaemia. It may

with re-

gards to prevalence of malaria parasitaemia, others

be that there is insufficient variation in socio-economic

status among the study population, since they all live

have found temperature at presentation to be associated

within the same community (Maiduguri) to allow for

with higher malaria prevalence. This study went further

significant differences to be detected. This may suggest

to demonstrate direct relationship between temperature

at presentation and parasite density . Hence, the ob-

that the overall socioeconomic status of a community

may be a more important determinant than individual

served difference could be attributed to the low parasite

status similar to findings in other studies . However,

density recorded in this study.

other studies have found low socioeconomic status to be

associated with higher malaria prevalences .

This

variation of the effect of socioeconomic status on ma-

laria prevalence could be due to variable method of so-

Conclusion and Recommendation

cioeconomic status classification; while Yusuf et al

used wealth index to measure socioeconomic status,

Prevalence of malaria parasitaemia was high in the

this study used parental educational status in combina-

population studied inspite of various control measures.

tion with parental occupation and expected income to

Malaria infection among this age group is characterized

determine the socioeconomic status of each child .

by low density parasitaemia which increases with the

However, the evidence with regard to vulnerability to

age and hence the need to interpret negative result with

the consequences of malaria by groups of lower socio-

caution. Age, gender, socio-economic status, tempera-

economic status is more consistent . This may reflect

ture at presentation and nutritional status as well as own-

lower access to effective means of treatment once in-

ership of ITN had no significant effect on the prevalence

fected.

of Malaria. Hence, there is need to strengthen and scale

up various malaria control programs while ensuring

Nutrition plays a major role in maintaining health, and

proper implementations of programs and activities

malnutrition appears to generate vulnerability to a wide

through effective monitoring and evaluation.

variety of diseases and general ill health including ma-

laria.

16,17

. In this study however, nutritional status did

Limitation

not have any effect on the prevalence and density of

malaria parasitaemia. This finding could be due to the

The study was carried out in a tertiary health facility

higher frequency of moderate under-nutrition as com-

which is a referral centre and thus could have underesti-

pared to severe form. The relationship between under-

mated the burden of malaria (which is usually treated at

nutrition and malaria has remained controversial for

the lower cadres of health care) in the general popula-

many years, though most review articles suggest that

tion.

under-nutrition is an important underlying risk factor for

infectious diseases in general

and for malaria in par-

ticular. More precisely, it has been shown that severe

Conflict of Interest: None

stunting induces down-regulation of the overall anti P.

Funding: None

falciparum IgG antibody response.

324

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