Incidence of Plasmodium infections and determinant factors among febrile children in a

district of Northwest Ethiopia; a cross-sectional study

Tadesse Hailu, Megbaru Alemu*, Wondemagegn Mulu, Bayeh Abera

Tadesse Hailu (Department of Medical Microbiology, Immunology and Parasitology, Bahir Dar
University)
Email:[email protected]
Megbaru Alemu (Department of Medical Microbiology, Immunology and Parasitology, Bahir
Dar University)
Email:[email protected]

Wondemagegn Mulu (Department of Medical Microbiology, Immunology and Parasitology,

Bahir Dar University)

Email: [email protected]

Bayeh Abera (Department of Medical Microbiology, Immunology and Parasitology, Bahir Dar
University)

Email:[email protected]

Corresponding author*

Megbaru Alemu (Assistant professor)

Department of Microbiology, Immunology and Parasitology, Bahir Dar University

PO Box 79, Bahir Dar, Ethiopia.

Email: [email protected]

Fax: +251 (0582) 20 59 32

1
Abstract

Background: According to the Ethiopian national malaria indicator survey of 2015, the highest

burden of plasmodia infection resided among the school-age children. Even though several

studies revealed various determinant factors of childhood malaria, consistency of findings is

lacking in Ethiopia and elsewhere. Hence exacting prevention and control measures couldn’t be

implemented so far.

Objectives: This study aimed to determine the incidence of plasmodium and determinant

factors among febrile children in Northwest Ethiopia.

Methods: This cross-sectional study was conducted from April 2016 to August 2016. Febrile

children were selected by systematic random sampling and Giemsa-staining technique was used

to identify plasmodium species. Statistical analysis was done via the SPSS 20statistical software

and data were summarized via percentages and frequencies. The bi-variate nd multi-variate

logistic regressions were used to measure strength of association between plasmodium and

determinant factors and rule out confounders, respectively.

Result: Among the 333 febrile children, 146 (43.8%) were positive for the Plasmodia. The

distributions of plasmodium in age groups 6-8, 9-10 and 11-14 were 47%, 50% and 40%,

respectively. Prevalence of plasmodium among male and female children was 44.2% and 43.5%,

respectively. Shorter distance from stagnant water (AOR (adjusted odds ratio) =43, 95% CI

(confidence interval):2.8-680.7; P<0.01), family size (AOR =14.7, 95% CI:(1.4-151.2; P=0.02),

outdoor sleeping (AOR =36.6, 95% CI:2.4-554.2; P<0.01, bed net use (AOR =21.1, 95% CI:2.9-

154.7; P<0.01), late bed time (AOR =31.9, 95% CI:2.8-371.3; P<0.01 and DDT spraying (AOR

2
=0.02, 95% CI:0.0-0.88; P<0.01) were the major determinant factors associated with malaria

infection.

Conclusion: The incidence of plasmodium infection is high among febrile children in the study

area. Shorter distance from stagnant water, larger family size, outdoor sleeping, irregular bed net

use, late night sleeping and not spraying of DDT are the major determinant factors for the high

incidence of malaria. Therefore, community mobilization and health education should be given

for the community to minimize risk of malaria.

Key words: Plasmodium, Incidence, Bed net, sleeping time, stagnant water

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Background

Malaria is one of the world's greatest challenges to be considered especially in resource poor

countries of the tropics and subtropics [1].There were approximately 214 million new malaria

cases and 438, 000 malaria deaths worldwide and the African Region harbored 88% of new

malaria cases and 90% of malaria deaths [ 2]. Of these mortalities, 60% occur in the sub Saharan

African children [3].

Malaria is also the leading public health problem and cause of outpatient visit accounting for

12% of cases in Ethiopia [4]. It is estimated that about 65% of the population is at risk and places

with altitude < 2000 meter above sea level are either malarious or potentially malarious [5].

Plasmodium falciparum represents about 65-75% of the total reported malaria cases, relative

frequency varying in time and space within given geographical ranges [2].

Previous studies revealed that the prevalence of malaria is still high in different endemic areas of

the country. For instance, high incidence of malaria among febrile individuals was reported in

Pawe (51.5%) [6], Dembecha (52%) and Quarit (72.7%) [7]. Ethiopia has documented a

remarkable reduction in the malaria mortality in children under five years of age in the last

decade. Yet, the school-age children were found to harbour the highest malaria infection among

all other age groups. It is well-known that regular utilization of long lasting insecticide treated

nets can significantly reduce malaria infection. However, in many areas of Africa where Ethiopia

is no exception, the school-age children sleep under nets less often than any other age group. In

such areas there exists a propensity for mothers sleeping under nets with their young children,

while older children slept under nets less frequently [16]. Surveys conducted in several African

4
nations revealed that school-aged children were the group least likely to sleep under an ITN

which left more than 30% of school-aged children unprotected [19].

Previous studies revealed different determinant factors of childhood malaria in malaria endemic

areas including knowledge [8], bed net utilization [9], sleeping outside [10], poor socio-

economic status [11] and residence [12]. However, consistent findings were not yet attained as

determinant factors vary with time, place and person in Ethiopia in general and the study area in

particular. Taking in to account the inconsistencies, we seek to asses factors associated with

childhood plasmodium infection to enable exacting preventive and control measures against

malaria among the vulnerable age group in Northwest Ethiopia.

Methods

Study design, period and area

This cross sectional study was conducted from April 2016 - August 2016 among febrile school

age children in Jawe district, Awe Zone, Amhara regional state, Northwest Ethiopia. The altitude

and temperature of the district are 648 – 1300 meters above sea levels and 16.68 0c - 37.60c,

respectively. According to health centers records, malaria remains the number one cause of

admissions and child morbidity and mortality in the district. Malaria transmission occurs

throughout the year with peaks after the two rain seasons. Jawe district has many water bodies

like Beles and Asihue rivers which possibly help for the breeding of malaria vectors throughout

the year.

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Sample size and Sampling technique

Systematic random sampling technique was employed to recruit the febrile school age children

in this study. The data was collected from two heath centers namely Jawe and Workmeda. The

sample size in each health center was allocated by considering the number of population in the

catchment areas.All febrile children aged 6-14 years, attending Jawe and Worekmeda health

centers and willing to participate in the study were included in the study. Febrile children

undertaking antimalaria or/and antibiotic drugs during the data collection time were excluded.

Data collection

Questionnaire: A structures questionnaire was used to collect data on demographic information,

determinant factors, explanatory variables and environmental related factors. The questionnaire

was filled by trained health officers via face to face interview of parents/guardian of the children.

Parasitological examination
Blood sample collection and examination: Blood sample was collected by finger prick from each

study participant for parasite detection. Both thick and thin blood film preparation was done on a

single slide. In the thick film preparation, three drops of blood were distributed over an area of

1cm2 at one end of the slide. Thin smear was also done by evenly distributing a drop of blood on

the other end the slide. Slides were labeled, dried, fixed with methanol alcohol (thin smear only),

and stained (using 10% Giemsa stain solution for 30 minutes), washed with distilled water and

air dried. Plasmodium was detected on the thick blood films whereas species identification was

done on the thin film.

Quality assurance

To ensure reliable data collection, training was given for laboratory technicians and health

officers on how they collect the data. Explanation about the study was also given before sample

6
collection. Application of standard procedures and accuracy of test results was supervised by

principal investigator. To eliminate observer bias, thick blood film slides were examined

independently with two experienced laboratory technicians and 10% of the thick blood film

slides was randomly selected and read by another technician as a quality control. The results of

their observation were recorded for later comparison on separate sheets.

Data analysis

Data were entered and analyzed using SPSS version 20 statistical software. The incidence of

Plasmodium was calculated using descriptive statistics and chi-square. Strength of association

between Plasmodium and determinant factors were calculated by bivariate analysis. Those

variables with P < 0.2 (Hosmer-Lemeshow goodness of fit test for logistic regression) in the

binary logistic regression were taken to multiple regression analysis and the AOR was calculated

to control potential confounders. P-values less than 0.05 were taken statistical significant.

Results

A total of 333 febrile school-age children were included in this particular study. The range and

mean age of the study participants’ were 8 and 11 years, respectively. The majority of cases

(57.4%) were in the age range 11 – 14 years. Most of the participants (98.5%) were Christianity

followers. Two hundred seventy three (82%) febrile cases were rural inhabitants (Table 1).

Table1: Socio-demographic factors of children infected with malaria in Jawe district, Northwest

Ethiopia, 2016.

Variables N Malaria status P value

Positive n (%) Negative n (%)
Age 6-8 70 33(47.1) 37(52.9) 0.30
9 - 10 72 36(50.0) 36(50.0)

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 11 - 14 191 77(40.3) 114(59.7)
Sex Male 163 72(44.2) 91(55.8) 0.46
Female 170 74(43.5) 96(56.5)
Religion Christian 328 144(43.9) 184(56.1) 0.62
Muslim 5 2(40.0) 3(60.0)
Residence Rural 273 117(42.9) 156(57.1) 0.26
Urban 60 29(48.3) 31(51.7)
Total
A total of 131 (91%) school children were infected with plasmodia among school children who

slept <=1km from the stagnant water. The number of plasmodia infected school children in DDT

sprayed house was 122 (87.8%). The prevalence of Plasmodium infection among school children

live in a family size >=5), sleep after 22:00 hours, sleep outside home and didn't sleep under bed

net were 110 (81.5%), 119 (89.5%), 127 (84.7), and 126 (94.7). respectively (Table 2).

Table 2: distribution plasmodia based on their determinant factors in Jawe district, Northwest

Ethiopia

Variables Malaria status

Total (N, %) Positive (N, %) Negative (N, %)
Distance from <=1km 144 (43.2) 131(91) 13 (9)
>1km 189 (56.8) 115 (60.8) 74 (39.2)
stagnant water
DDT spray No 139 (41.7) 122 (87.8) 17 (12.2)
Yes 194 (58.3) 24 (12.4) 170 (87.6)
Family Size >5 135 (40.5) 110 (81.5) 25 (18.5)
<5 198 (59.5) 36 (18.2) 162 (81.8)
Bed time After 22:00 133 (39.9) 119 (89.5) 14 (10.5)
Before 22:00 200 (60.1) 27 (13.5) 173 (86.5)
Sleeping Yes 150 (45) 127 (84.7) 23 (15.3)
No 183 (55) 19 (10.4) 164 (89.6)
outdoor
Sleeping under No 133 (39.9) 126 (94.7) 7 (5.3)
Yes 200 (60.1) 20 (10) 180 (90)
bed net
Total 300 (100) 146 (43.8) 187 (56.2)

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 The odds of malaria infection was 98% lower in children who live in DDT sprayed homes than

non-sprayed counter parts (AOR: 0.02 [95% CI: 0.0 - 0.88]. The odds of Plasmodium infection

was 43.2 times higher in children who live near stagnant water (AOR: 43.2 [2.75 – 680.7]). The

odds of malaria infection was 36.6 times higher in children who sleep outside home (AOR: 36.6

[2.4 – 554.2]) (Table 3).

Table 3: Determinants of malaria infection among children in Jawe district Northwest Ethiopia

Variables Malaria status COR[95%CI] AOR[95%CI] P-value

Positive Negative

(n) (n)
Distance from <=1km 131 13 0.04[0.0 - 0.33] 43.2[2.8 – 680.7] <0.01
>1km 115 74
stagnant water
DDT spray No 122 17 0.02[0.0 - .19] 0.02[0.0 – 0.88] <0.01
Yes 24 170
Family Size >5 110 25 0.07[0.01 - 0.70] 14.74[1.4 – 151.2] 0.02
<5 36 162
Bed time After 119 14 0.03[0.0 - .36] 31.9[2.8 – 371.3] <0.01

22:00
Before 27 173

22:00
Sleeping Yes 127 23 0.03[0.0 - 0.42] 36.6[2.4 – 554.2] <0.01
No 19 164
outdoor

Sleeping under No 126 7 0.05[0.01 - 0.35] 21.1 [2.8 – 154.7] <0.01

Yes 20 180
bed net the

previous night

9
Discussion

Malaria remains one of the most important causes of morbidity and mortality among school-age

children. Currently, there is an increasing interest in malaria in school-age children as malaria

may interfere with a child’s educational development [13]. Malaria is also one of the major

causes of school absenteeism in school-age children of malaria-endemic areas. An earlier study

conducted in Nigeria revealed that an average of three school days was lost per episode of

malaria [14]. Another study also indicated that infected primary school children had lower test

scores for abstract reasoning and sustained attention compared with uninfected children in

Uganda [15].

Multivariate logistic regression revealed significant associations between malaria infection and

several independent variables. For instance, regular bed net utilization was associated with lower

odds of malaria infection in our study. The reported prevalence of sleeping under a net in this

study was 60.1%, indicating significant numbers of children were not protected in the study area.

This goes in line with surveys in most malaria endemic areas of Africa where school-age

children sleep under nets less often than any other age group. For instance, results obtained from

Malawi (16), and Cameron (17) revealed that school-age children slept under bed net less

frequently. In these endemic regions it is the tendency that mothers slept under nets with their

young children, while other household members slept under nets less frequently. It is often well-

known that young children are vulnerable to malaria morbidity and mortality in malaria-endemic

communities like the current study area. On the other hand, older children and adults are

perceived to be less at risk and may use bed nets less [16]. This may, in part, explain higher

infection prevalence of malaria among school-age children in the study area.

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The odds of being infected by malaria were 21 times higher among those who did not sleep

under long-lasting insecticide treated net (LLIN) than those who utilized it regularly. This was

supported by previous studies where there existed evidence that regular use of LLIN

significantly lowered the risk of malaria at individual level [13, 17-18]. However, universal

coverage is challenged by the fact that school-age children have attracted relatively little

attention as a group in need of special measures to protect them against malaria so far. As

children become older and more independent, parents have less control over the time when they

go to bed, where they sleep, and whether they use a net, frequently resulting in low net coverage

in children in this age group. For instance household surveys conducted in several African

countries revealed that school-aged children were the group least likely to sleep under an ITN

which left more than 30% of school-aged children unprotected [19]. Similarly, low ITN usage

rates have been observed among school-age children in Cameroon [20], Kenya [21], Malawi and

Uganda [15, 22]. Hence malaria education should be provided at schools as it substantially

increases the use of bed nets a previous study elsewhere.

Our study also showed that Indoor residual spraying (IRS) significantly decreased incidence of

malaria among school children. The odds of malaria infection were 0.02 times lower among

children from households with indoor residual spraying. This was supported by a study in

Tanzania where repeated IRS campaigns reduced malaria parasitaemia from 73% to 4% in

school-age children [23]. Another recent study in Kenya also showed that targeted IRS halved

malaria incidence in school children [24].

Despite the fact that Anopheles mosquitoes can fly considerable distances, multivariate analysis

showed a statistically significant association between the estimated distance of residents to

11
stagnant water and plasmodia infection in the current study area. This was consistent with

previous study [25].

Family size had also showed statistically significant association with malaria blood slide

positivity which is similar with other studies in Ethiopia [26-27]. This might be due to

inadequate number of bed nets to family size leaving certain members of the household

unprotected. Jawe district has higher transmission rate of plasmodia. As a result, school-age

children who didn’t sleep under bed net due to in adequate bed net distribution regarding family

size possible infected with Malaria.

In our study, about 45% of the participants reported outdoor sleeping at some time and the

multivariate analysis indicated causal link between sleeping outdoors and Plasmodium infection.

The odds of Plasmodium infection were 37 times higher among those who experienced outdoors

at some time. This could predispose children to the infective mosquito bites where anophelines

exhibit exophagic and exophilic behavior. This outdoor sleeping could further jeopardize the

wellbeing of children with respect to malaria as bed nets are not usually hanged during outdoor

sleeping [10]. specific barriers of using bed nets in the outdoors such as not wanting or not

knowing how to hang, the fluidity of sleeping spaces and movement from outdoors to indoors

during the night were reported elsewhere [10].

Our study also indicated significant associations of late night and Plasmodium infection. While

children sleep late, the chance of vector-human contacts was enhanced and unfortunately late

nights usually coincide with the peak biting hours of nocturnal anophelines [10].

Generally to minimize the risk of infection and impacts of malaria among school-age children,

endemic countries should do a lot on factors influencing malaria preventions and controls.

12
Community mobilization on adequate bed net distribution and utilization by considering the

family size and environmental management for vector control and early malaria diagnosis and

treatment should be implemented in endemic areas (30-31).

Conclusion

The incidence of Plasmodium infection was high among febrile children in Jawe district.

Distance from stagnant water, family size, outdoor sleeping, bed net use, late night sleeping and

DDT spraying are the major determinant factors for the high incidence. Therefore, community

mobilization and health education on proper bed net utilization, early diagnosis and timely

getting treatment should be given.

Abbreviations

MOH: Ministry of Health; DDT: Dchlorodiphenyltrichloroethane; CI: Confidence Interval; OR:

Odds ratio; AOR: Adjusted Odds Ratio; LLIN: long lasting insecticide treated net.

Declarations

Ethics approval and consent to participate

Ethical approval was granted by Bahir Dar University, College of Medicine and Health Sciences.

The Parents/guardians were informed of their children’s participation and gave informed written

consent for their children to participate. Assents were also collected from children. Children who

were found to be infected by the Plasmodium were treated with anti-malaria drugs as per the

current malaria treatment quid line of the country.

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Consent for publication

Consent for publication is not applicable as individual data such as images and videos did not

accompany this manuscript.

Availability of data and materials

Data were collected and analyzed based on the stated methods and materials to generate findings

of this study. All the data were incorporated into the manuscript and no supplementary files

accompanied the submission. The original data supporting this finding will be available at any

time upon request.

Competing interests

Authors declared they have no conflicting interest.

Funding

The research project was not funded by any organization.

Authors’ contributions

Considerable contributions were made by all authors during the conception, design, and

acquisition of data, analysis, and interpretation of data to this study. They have drafted and

approved the final version of the manuscript and declared to bear the responsibility of all aspects

of the research work.

Acknowledgment

We are thankful to laboratory personnel for their devotion to malaria microscopy. We also thank

the children for their participation.

14
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