Nigerian Journal of Paediatrics

Malaria Chemoprophylaxis The use and abuse by caregivers of children in south east Nigeria

Niger J Paediatr 2019; 46 (3): 140 — 144

ORIGINAL

Ndu IK

CC – BY

Malaria chemoprophylaxis: The

Uleanya ND

Ekwochi U

use and abuse by caregivers of

Nduagubam OC

children in South east Nigeria

Edelu BO

Asinobi IN

Ayuk AC

Bisi-Onyemaechi A

Osuorah DIC

DOI:http://dx.doi.org/10.4314/njp.v46i3.4

Accepted: 17th September 2019

Abstract : Introduction: Malaria

section, collected information on

still remains a major cause of

outcome variables which assessed

Uleanya ND (

)

morbidity and mortality in chil-

respondents’ level of practice of

Ndu IK, Ekwochi U

dren despite concerted efforts to

chemoprophylaxis.

Nduagubam OC, Asinobi IN

reverse this. Chemoprophylaxis

Results: A total of 318 (77.2%)

Department of Pediatrics

involves the use of anti malarial

caregivers

give

antimalarial

College of medicine

drugs to prevent malaria infection

prophylaxis to their children.

Enugu State University of Science

humans.

However

the

Mothers without tertiary education

and Technology, Enugu

i n c r e a s i n g

r e s i s t a n c e

( χ = 12.90, P = 0.00) and those

Email: nulesa2001@yahoo.com

of plasmodium to medications has

from

middle

and

lower

limited

the

effectiveness

socioeconomic classes ( χ =15.76,

Edelu BO, Ayuk AC

chemoprophylactic regimens used

P = 0.00) were significantly more

Bisi- Onyemaechi A

in the past. This study will

likely

administer

malaria

Department of Pediatrics

explore

the

perception

chemoprophylaxis

their

College of medicine

caregivers about these practices

children.

University Nigeria, Enugu Campus

and determine the proportion of

Conclusion: The misconception on

Email: onyedelu@yahoo.com

caregivers who treat their children

malarial chemotherapy could por-

for

malaria

without

meeting

tend treatment failure if not con-

Osuorah DIC

standard criteria.

trolled.

Extensive

public

Medical Research Council UK,

Methodology: This cross-sectional

enlightenment programs on the

The Gambian Unit, Fajara, Gambia

descriptive study, was carried out

guidelines for use of anti-malarial

Email: chidi.osuorah@yahoo.com

over a 3-month period, from

will go a long way in ensuring

March 2017 to June 2017. Struc-

rational use of anti-malarial drugs

tured questionnaires accompanied

in the fight against malaria

by informed consent forms were

particularly in high burden areas

sent to parents of selected pupils

such as Nigeria.

through their children. The first

section of the questionnaire was

Key words: Malaria, Chemopro-

about socio-demographic features

phylaxis, Children, Nigeria

of participants while the second

Introduction

According to the World Health organization (WHO)

children with suspected malaria should have a parasi-

Malaria still remains a major cause of morbidity and

tological confirmation of the diagnosis before treatment

mortality in children despite concerted efforts to reverse

is given; as part of efforts to reduce resistance and use

scarce resources appropriately. Current practices in our

this and over three billion people live in areas at risk of

malaria transmission. In 2015 alone, 214 million new

health institutions also uphold this decision. Methods of

cases of malaria were reported and 438,000 deaths oc-

parasitological confirmation commonly used include

microscopy and malaria rapid diagnostic test (RDT).

curred. In Nigeria,there are an estimated 100 million

malaria cases with over 300,000 deaths per year. Also,

The increasing resistance of Plasmodium to medications

malaria accounts for about 60% of outpatient visits and

has limited the effectiveness of chemoprophylactic

30% of hospitalizations among children under five years

regimens used in the past and in areas of endemicity.

of age in Nigeria. Malaria is however both preventable

Chemoprophylaxis involves the use of anti malarial

and treatable, and effective preventive and curative tools

drugs to supress and prevent the establishment of infec-

have been developed.

tion in the humans. Chemoprophylactic efforts have also

141

been

hindered

cost

and

programmatic

and benefits of the study as well as informed consent

difficulties. The National malaria treatment guideline

6,7

forms was given to the selected parents. Some of the

for Nigeria stipulates that chemoprophylaxis should be

information required included sociodemographic data of

limited for use in those with sickle cell anemia and non-

the parents, number of children per parents, parameters

immune visitors because of risk for severe disease.

that assessed respondents’ level of general use of anti

Intermittent preventive treatment of malaria is also

malarial drugs by parents, the level of practice of che-

recommended for all pregnant women and sometimes

moprophylaxis by parents and factors that influenced the

for children under five during seasonal outbreaks.

use of chemoprophylaxis by caregivers. Parental social

Home treatment of malaria by mothers/caregivers with-

class was obtained using Oyedeji’s method.

out seeing a doctor or health worker, is a common prac-

tice.

9,10

However, this practice is not in keeping with the

Data analysis

"Test and treat" recommendation of the WHO and

could lead to wastage of lean financial resources of the

All the data obtained were analyzed using the IBM Sta-

family as well as drug resistance.

tistical Package for Social Sciences version 21 (SPSS

This study will explore the perception of mothers/

Inc., Chicago, IL). Continuous variables were reported

caregivers about these practices and determine the pro-

as mean, median and standard deviation. While categori-

portion of caregivers who treat their children for malaria

cal variables were reported in percentages. Tables and

without meeting standard criteria. The findings in this

figures were constructed as appropriate. Chi-square was

study may positively influence the on-going fight

used to test for significance between categorical vari-

against malaria.

ables. Statistical significance was set at p<0.05.

Methods

Study design and area

Results

This was a descriptive cross-sectional study carried out

There were a total of 412 respondents, mostly females

among parents of primary school children in Enugu me-

(77.9%) Their ages ranged from 17 years to 78 years

tropolis of Nigeria from March to June 2017.The me-

with a mean age of 25.6 + 17.4 years. Most (81.1%) of

tropolis is made up of three local government areas –

the respondents reside in the urban area giving an urban:

Enugu North, Enugu East and Enugu South.

rural ratio of 4.5:1.

The number of children per

caregiver were grouped with distribution as follows: 1 –

Ethical consideration

2 children (176,42.7%), 3 – 4 (149, 36.2%), 5 – 6 (75,

18.2%), 7 and above (12, 2.9%).

Ethical clearance for the proposal was obtained from

A greater proportion of the caregivers (62.7%) had

the Enugu State University Teaching Hospital Health

tertiary education, while only seven (1.7%) were without

Research and Ethics Committee (ESUTHP/C-MAC/

formal

education.

terms

socioeconomic

RA/034/163). Furthermore, approval was obtained from

classification (SEC), 220 (53.5%) belong to upper SEC,

the Enugu State Ministry of Education, school proprietor

while 98 (23.7%) and 94 (22.8%) belong to middle and

(s), Head teachers and class teachers as well as parents

lower SEC respectively.

of the respondents. Informed consent – both verbal and

Most of the caregivers (97.1%) used orthodox

written – were obtained from each child’s parents/

antimalarial to treat their children when malaria is

guardian. Confidentiality was maintained throughout

suspected, while 2.9% used herbal medications. The

and after the study.

antimalarials used are as shown in figure 1. The most

commonly

used

antimalarial

was

Artemeter/

Sampling technique

Lumefantrine.

Multi-staged sampling involving stratified and simple

A total of 318 (77.2%) caregivers gave antimalarial

random methods was used. The number as well as the

prophylaxis to their children. The sources of the

ratio of public to private primary schools in the two ran-

medications are as shown on table 1.

About half

domly selected local government areas were used to

(50.9%) of these caregivers give antimalarial to other

determine the number of pupil’s parents selected in the

siblings when one child is being treated for malaria.

area. In each school selected, the participants were

Mothers without tertiary education ( χ = 12.90, P = 0.00)

selected by simple random sampling using a statistical

and those from middle and lower socioeconomic classes

table of random numbers. Where the selected pupil’s

( χ =15.76, P = 0.00) were significantly more likely to

parents declined consent to participate, the pupil was

administer malaria chemoprophylaxis to their children,

excluded from the study and the pupil sitting next to

tables 2 and 3. The place of residence ( χ = 0.01, P =

him/her selected.

0.93) or number of children ( χ = 1.50, P = 0.22) did not

significantly

influence

the

practice

malaria

Data collection

chemoprophylaxis, tables 4 and 5. Situations in which

caregivers administer malaria chemoprophylaxis to their

A pretested, self-administered questionnaire containing

children are shown in table 6.

due explanation and education on the content, purpose

142

Table 1: Sources of prescription for prophylactic treatment

Fig 1: Bar Chart showing the drugs used by caregivers for

Source

Frequency

Percentage

home treatment of malaria in their children

(N=318)

Doctors’ prescription based on

209

65.7

personal request

Based on Doctors’ Previous

16.7

prescription

Self-prescription

8.2

Patent Medicine Dealers/

155

48.7

Pharmacists

Table 2: Relationship between mothers’ educational

quaification and administration of malaria chemoprophylaxis

Level of edu-

Malaria chemoprophylaxis use

Total (%)

cation

Yes (%)

No (%)

Tertiary

156 (71.2)

63 (28.8)

219 (100.0)

Below tertiary

91 (89.2)

11 (10.8)

102 (100.0)

Total

247 (76.9)

74 (23.1)

321 (100.0)

Discussion

χ = 12.90, p = 0.00

This study illustrated practical realities concerning

Table 3: Relationship between caregivers’ socioeconomic

malaria

chemoprophylaxis

children

their

class and administration of malaria chemoprophylaxis

caregivers in Enugu, which has implications for the

SEC

Malaria chemoprophylaxis use

Total (%)

implementation of national malaria treatment guidelines

Yes (%)

No (%)

of Nigeria. The predominance of female respondents

Upper

152 (69.1)

68 (30.9)

220 (100.0)

supports the prevailing socio-cultural conditions in this

Middle

83 (84.7)

15 (15.3)

98 (100.0)

part of the world where mothers/ female caregivers are

Lower

83 (88.3)

11 (11.7)

94 (100.0)

more closely involved in the health needs of children/

Total

318 (77.2)

94 (22.8)

412 (100.0)

wards and are seen more in health facilities seeking

healthcare for their children.

12-15

χ =15.76, p = 0.00

The study shows that the use of herbal medication to

*SEC: Socioeconomic class

treat children with malaria is not a common practice in

Enugu. This may be a reflection of their level of

Table 4: Relationship between place of residence and use of

education and socio-economic class, as a greater

malaria chemoprophylaxis

proportion of the caregivers had tertiary education and

Malaria chemoprophylaxis use

were from the higher socio-economic class. Similarly,

No of children

Yes (%)

No (%)

Total (%)

an earlier study in Enugu had shown a low rate of herbal

medication use for malaria treatment.

Urban

257 (76.9)

77 (23.1)

334 (100.0)

Rural

59 (78.7)

16 (21.3)

75 (100.0)

Total

316 (77.3)

91 (22.7)

409 (100.0)

Despite the high level of education and socio-economic

χ = 0.01, p = 0.93

status of the caregivers in this study, majority of them

gave malaria chemoprophylaxis to their children against

Table 5: Relationship between number of children and use of

the provisions of the national malaria treatment

malaria chemoprophylaxis

guideline. Unfortunately, there’s paucity of studies on

Malaria chemoprophylaxis

the use of malaria chemoprophylaxis in children living

use

in malaria endemic areas. Our study revealed that the

No of children

Yes (%)

No (%)

Total (%)

use of malaria chemoprophylaxis was more common

1-4

246 (75.7)

79 (24.3)

325 (100.0)

among mothers without tertiary education and those

72 (82.8)

15 (17.2)

87 (100.0)

from middle and lower socio-economic classes. This

Total

318 (77.2)

91 (22.8)

412 (100.0)

attitude is worsened by the belief on the part of

caregivers that most if not all bouts of fever in our

environment are due to malaria. In addition there is the

χ = 1.50, p = 0.22

low utilization of malaria diagnostic tests and over-

Table 6: Situations in which caregivers administer malaria

reliance on clinical signs and symptoms for the

chemoprophylaxis to their children

diagnosis by health care workers

13,18-21

Situation

Frequency

Percentage

(n=318)

The practice of giving anti-malarial to other siblings

Return to school from holidays

24.0

when one child is being treated for malaria was observed

Travel to the village

20.5

in more than half of the caregivers. This may be due to

During holidays/ festivities

6.3

the belief that since the children share same home,

Long duration from last antimalarial

116

36.6

there’s likelihood of other siblings being bitten by the

therapy

same mosquitoes and hence maybe incubating malaria.

Observation of mosquito bites on

13.8

Falciparum malaria has been reported to present in

the skin

simultaneously. However,

family

members

the

143

occurance of malaria in one member should not be an

for children on request by care givers as found in this

indication to treat other family members in an endemic

study.

area except the individual is symptomatic and is

confirmed by a laboratory test. Long duration from last

anti- malarial therapy, a child’s return to school after

holidays and trips to the village should not indications

Conclusion

for

antimalarial

chemoprophylaxis.

This

practice

amounts to abuse of anti-malarial drugs and show

This study has demonstrated the misuse of antimalarial

obvious knowledge gaps on the part of caregivers and

chemotherapy by caregivers and the indiscriminate use

healthcare providers regarding the provisions of the

of anti-malarial drugs as prophylaxis outside the provi-

policy guidelines on use of malaria chemoprophylaxis in

sions of the national malarial guidelines. This could lead

children. This shows a clear need for extensive public

to treatment failure and development of drug resistance

enlightenment campaign on the provisions of the

if not controlled.

national malaria policy.

The pattern of prescription of anti-malarials in this study

Recommendation

is similar to those of many studies from both Nigeria

and other African countries,

4,16,23,24

and shows a clear

There needs to be an extensive public enlightenment

preference for artemesinin-based combination therapy

programs

the

guidelines

for

use

anti-

(ACT), particularly the Artemisinin-Lumefantrin (AL)

malariassls.Also, regulation of access to anti-malarial

combination, which is the policy first line drug and

drugs and instituting ways to ensure and enforce

indicates providers’ confidence on the efficacy of the

adherence to the National Malarial Policy guidelines by

regimen. A large number of the prescriptions for

health workers will go a long way in ensuring rational

chemoprophylaxis were written by doctors on personal

use of anti-malarial drugs, ensure drug efficacy and

request by the caregivers of children. This finding could

improved outcome in the fight against malaria

partly explain why AL was the most commonly used

particularly in high burden areas such as Nigeria.

drug for malaria. However, the use of anti-malarial

drugs are neither in line with “test and treat” policy or

the recommendations for malaria prophylaxis in children

Authors contribution

as contained in the national malarial guideline of Nigeria

NIK: Conception, questionnaire design, directed data

and therefore should be of concern. Studies have shown

analysis, and mauscript writing. UND, UE, NOC, EBO,

limited use of laboratory diagnosis prior to malaria

AIN, AAC. BOA and ODIC: Questionnaire design, data

treatment, even with the availability of rapid diagnostic

collection, literature review, manuscript writing. EBO:

tools.

13,18-20

This is worrisome as a good number of

data analysis

doctors still rely on their clinical skill in making a

Conflict of interest: None

diagnosis of malaria and prescribe anti-malarial drugs

Funding: None

References

WHO/UNICEF report: Malaria

4. Graz B, Willcox M, Szeless T,

7. Fischer PR, Bialek R.

MDG target achieved amid

Rougemont A. " Test and treat"

Prevention of malaria in

sharp drop in cases and

or presumptive treatment for

children . Clin Infect Dis .

mortality, but 3 billion people

malaria in high transmission

2002;34:493-8.

remain at risk. Saudi Med J .

situations? A reflection on the

Federal Ministry of

2015;36:1377-8.

latest WHO guidelines.

Health Nigeria.National

United States Embassy in Ni-

Malaria J. 2011;10:136.

Guidelines for Diagnosis and

geria. Nigeria malaria facts

5. Berzosa P, de Lucio A, Romay-

Treatment of Malaria. Third

sheet. Dec 2011. http://

Barja M, Herrador Z, González

ed. 2015: p. 40.

www.nmcp.gov.ng/Downloads

V, García L et al. Comparison

Hopkins H, Talisuna A,

(assessed2019 Apr 13)

of three diagnostic methods

Whitty C, Staedke S: Impact

Kio JO, Agbede CO, Olayinka

(microscopy, RDT, and PCR)

of home-based management of

FE, Omeonu PE, Dire-Arimoyo

for the detection of malaria

malaria on health outcomes in

Y. Knowledge, attitudes and

parasites in representative

Africa: A systematic review of

practices of mothers of under-

samples from Equatorial

the evidence. Malaria J .

five regarding prevention of

Guinea. Malaria J.

2007;6:134.

malaria in children: Evidence

2018;17:333.

from Ogun State, Nigeria. Int J

Kain KC, Shanks GD,

Human Soc . 2016;21:01-07

Keystone JS. Malaria

chemoprophylaxis in the age of

drug resistance. I. Currently

recommended drug regimens.

Clin Infect Dis . 2001

Jul;33:226-34.

144

10. Chipwaza B, Mugasa JP,

16. Edelu BO, Ndu IK, Igbokwe

21. Onwujekwe O, Uzochukwu B,

Mayumana I, Amuri M,

OO, Iloh ON. Severe

Dike N, Uguru N, Nwobi E,

Makungu C, Gwakisa PS. Self-

falciparum malaria in children

Shu E. Malaria treatment per-

medication with anti-malarials

in Enugu, South East Nigeria .

ceptions, practices and influ-

is a common practice in rural

Niger J Clin Pract .

ences on provider behaviour:

communities of Kilosa district

2018;21:1349-55.

comparing hospitals and non-

in Tanzania despite the reported

17. Oshikoya K, Senbanjo I. Fever

hospitals in south-east Nige-

decline of malaria. Malaria J .

in children: Mothers’

ria. Malaria J . 2009;8:246.

2014;13:252.

perceptions and their home

22. Babu TA, Devagaran VV.

11. Oyedeji GA. Socioeconomic

management. Iran J Pediatr .

Simultaneous presentation

and cultural background of hos-

2008;18(3):229-36.

of Plasmodium vivax malaria

pitalised children in Ilesha.

18. Zurovac D, Githinji S, Me-

in two siblings following visit

Niger J Paediatr . 1985;12:111-

musiD, Kigen S, Machini B,

to an endemic area: An

17.

Muturi A et al. Major improve-

uncommon presentation. J

12. Mangham LJ, Cundill B,

ments in the quality of malaria

Med Trop . 2014;16:107-8.

Ezeoke O, Nwala E,

case-management under the

23. Ezenduka CC, Ogbonna BO,

Uzochukwu C, Wiseman V et

“test and treat” policy in

Ekwunife OI, Okonta MJ,

al. Treatment of uncomplicated

Kenya. PLoS One .

Esimone CO. Drugs use pat-

malaria at public health facili-

2014;9:e92782.

tern for uncomplicated malaria

ties and medicine retailers in

19. Reyburn H, Ruanda J, Mwer-

in medicine retail outlets in

southeastern Nigeria. Malaria

inde O, Drakeley C. The contri-

Enugu urban, southeast Nige-

J . 2011;10:155.

bution of microscopy to target-

ria: implications for malaria

13. Meremikwu M, Okomo U,

ing antimalarial treatment in a

treatment policy. Malaria

Nwachukwu C, Oyo-Ita A, Eke

low transmission area of Tan-

J.2014;13:243.

-Njoku J, Okebe J et al. Anti-

zania. Malaria J . 2006;5:4.

24. Ezenduka CC, Okonta MJ,

malarial drug prescribing prac-

20. Uzochukwu BS, Chiegboka

Esimone CO. Adherence to

tice in private and public health

LO, Enwereuzo C, Nwosu U,

treatment guidelines for un-

facilities in south-east Nigeria:

Okoroafor D, Onwujekwe OE

complicated malaria at two

a descriptive study. Malaria J .

et al. Examining appropriate

public health facilities in Ni-

2007;6:55.

diagnosis and treatment of ma-

geria; Implications for the

14. Sears D, Kigozi R, Mpimbaza

laria: availability and use of

‘test and treat’ policy of ma-

A, Kakeeto S, Sserwanga A,

rapid diagnostic tests and ar-

laria case management. J

Staedke SG et al. Anti-malarial

temisinin-based combination

Pharm Policy Pract .

prescription practices among

therapy in public and private

2014;7:15.

outpatients with laboratory-

health facilities in south east

confirmed malaria in the setting

Nigeria. BMC Public Health .

of a health facility-based senti-

2010;10:486.

nel site surveillance system in

Uganda. Malaria J .

2013;12:252.

15. Thwing JI, Njau JD, Goodman

C, Munkondya J, Kahigwa E,

Bloland PB et al. Drug dispens-

ing practices during implemen-

tation of artemisinin-based

combination therapy at health

facilities in rural Tanzania,

2002 – 2005. Trop Med Int

Health . 2011;16:272 – 79.