Addis Ababa University

Faculty of Medicine
Department of Community Health

Prevalence of Malaria and its influencing factors in Awassa District,

Southern Ethiopia.

By

Getachew Alemu

A thesis to be submitted to the school of graduate studies, Addis

Ababa University in partial fulfillment of the requirements for
master of public health.

June 2006
Addis Ababa, Ethiopia
 Addis Ababa University

School of graduate studies

Prevalence of Malaria and its influencing factors in

Awassa District, Southern Ethiopia.

By

Getachew Alemu

Department of Community Health

Faculty of Medicine

Advisor: Prof. Ahmed Ali (MPH, Ph.D.)

June 2006

Addis Ababa, Ethiopia

 Acknowledgement

I would like to thank Prof. Ahmed Ali for devoting all his time & energy in correcting and

shaping both my proposal and final paper. I am grateful to Community Health Department

of Addis Ababa University for funding my study. I would also like to extend my heartiest

appreciation to Dr. Shiferaw Teklemariam, Southern Nation nationalities people’s

Regional health bureau, Sidama Zone Health Department, Awassa Special Zone Health

Department, Awassa Health Center for their material, manpower & moral support during

data collection.

i
 Table of contents

Acknowledgement.............................................................................................. i
List of tables..................................................................................................... iv
List of Figures .................................................................................................. v
List of Acronyms.............................................................................................. vi
Abstract …………………………………………………………………………………vii
1. Introduction.................................................................................................. 1
2. Literature Review ......................................................................................... 3
Malaria morbidity and mortality.................................................................................................... 3
Prevention and control .................................................................................................................... 5
Prevalence of malaria ...................................................................................................................... 6
Splenomegaly.................................................................................................................................... 7
Socio-demographic factors .............................................................................................................. 9
Age dependence of malaria................................................................................................................................ 9
Climatic and geographical parameters and malaria..................................................................... 9
Socio-economic parameters........................................................................................................... 10
Mosquito net use and malaria .......................................................................................................................... 10
3. Objective ..................................................................................................... 12
General Objective........................................................................................................................... 12
Specific Objectives ......................................................................................................................... 12
4. Materials and Methods .............................................................................. 13
4.1. Study area and Population ..................................................................................................... 13
4.2. Study Design ............................................................................................................................ 13
4.3. Sample size determination...................................................................................................... 14
4.4. Inclusion and Exclusion Criteria ........................................................................................... 14
4.4.1. Inclusion criteria .................................................................................................................................... 14
4.4.2. Exclusion criteria ................................................................................................................................... 14
4.5. Sampling Procedures .............................................................................................................. 14
4.6. Data collection ......................................................................................................................... 15
4.7. Study Variables ....................................................................................................................... 15
4.7.1. Independent............................................................................................................................................ 15
4.7.2. Dependent .............................................................................................................................................. 15
4.8. Data processing and Analysis................................................................................................. 16
4.9. Data Quality Control .............................................................................................................. 16
4.10. Ethical Consideration ........................................................................................................... 16
5. Results......................................................................................................... 16
Socio demographic characteristics of respondents...................................................................... 17
Health service and environmental factors ................................................................................... 18
Clinical and laboratory findings ................................................................................................... 21
Socio demographic factors and malaria....................................................................................... 24
Health service and environmental determinants of malaria ...................................................... 26
Multivariate Logistic regression analysis results ........................................................................ 31
6.Discussion........................................................ Error! Bookmark not defined.
Strengths and limitations............................................................................................................... 37
Strengths .......................................................................................................................................................... 37
Limitations ....................................................................................................................................................... 37

ii
Conclusions ..................................................................................................................................... 37
Recommendations .......................................................................................................................... 38
References....................................................................................................... 42
Annexes........................................................................................................... 43
Annex 1: Questionnaire for data collection ................................................................................. 43
Annex 2: Laboratory results reporting format ........................................................................... 47
Annex 3: Consent Form................................................................................................................. 48

iii
 List of tables

Table.1. Socio demographic characteristics of household respondents, Awassa woreda, 2006.

..............................................................................................Error! Bookmark not defined.
Table.2.Distribution of study subjects by selected demographic, health Service and
environmental factors...........................................................................................................20
Table.3. Distribution of children 2-9 years by clinical presentations & Laboratory findings,
Awassa, 2006. ......................................................................................................................21
Table.4. Comparison of reported fever prevalence in children 2-9 years ....................................24
of age with selected socio demographic factors, Awassa, 2006. .................................................24
Table .5. Comparison of Malaria parasitological rate with selected socio demographic
characteristics, Awassa Woreda, 2006.................................................................................25
Table.6. Comparison of enlarged spleen prevalence in children 2-9yrs with selected socio
demographic factors, Awassa Woreda, 2006.......................................................................26
Table.7. Comparison of reported fever prevalence in children 2-9 years of age by health service
and environmental factors, Awassa Woreda, 2006..............................................................27
Table.8.Comparisonof Malaria parasitological prevalence in children 2-9years with selected
health service and environmental factors, Awassa Woreda, 2006.......................................28
Table.9. Comparison of enlarged spleen prevalence with selected health service and
environmental factors, Awassa Woreda, 2006.....................................................................30
Table.10.Multivariate Logistic regression analysis of reported fever prevalence in children 2-9
years of age by socio demographic and environmental factors, Awassa, 2006..................32
Table.11. Multivariate logistic regression analysis of Malaria parasitological rate with selected
socio demographic and environmental factors, Awassa Woreda, 2006..............................33
Table.12.Multivariate logistic regression analysis of enlarged spleen prevalence in children with
selected socio demographic and environmental factors, Awassa Woreda, 2006.................34

iv
 List of Figures

Figure.1 Distribution of malaria prevalence by residence locality, Awassa woreda, 2006 .22

Figure.2. Distribution of malaria prevalence by age, Awassa woreda, 2006.......................23

Figure.3 Distribution of malaria prevalence by sex, Awassa, woreda, 2006.......................23

v
 List of Acronyms

ACT: Artemesinin Combination Therapy

An: Anopheles

API: Annual Parasite Index

DDT: Dichlorodiphenyltrichloroethane

DHS: Demographic and Health Survey

HH: House Hold

HP: Haemoparsite

IEC: Information Education Communication

IRS: Indoor Residual Spraying

ITNs: Insecticide Treated bed Nets

MOH: Ministry Of Health

PF: Plasmodium falciparum

PV: Plasmodium vivax

SNNPR: Southern Nation Nationalities and Peoples’ Region

SP: Sulphadoxine-Pyrimethamine

WHO: World Health Organization

vi
 ABSTRACT
Malaria is a leading public health problem in Ethiopia where an estimated 68% of the

population lives in malarious areas. In 2005, malaria has been reported as the first leading

cause of morbidity & mortality accounting for 48% of out patient consultation, 20%

admissions and 24.9% inpatient deaths. It has also been documented in the nationwide

child survival study that malaria affected school attendance by 20% and contributes to 47%

of the child deaths in Ethiopia.

Knowledge on local malaria situations is an important step in planning intervention and

control activities since the transmission dynamics and determinants differ from place to

place and in time. In the study area there is scarcity of community based studies which

could provide recent information on the epidemiology of malaria for planning and

implementation of effective prevention and control activities.

A cross sectional study was carried out in Bushulo, Awassa District ,Sidama Zone,

SNNPR from February 2006 to May 2006 with the objective to estimate prevalence of

malaria and Factors influencing it.

A total of 487 children and 200 households were studied from four rural localities selected

by simple random sampling and using proportional to size allocation to each locality. The

response rate was 98.2%. Household and clinical data were collected using semi-structured

questionnaires and a format was used for laboratory data. Blood samples were taken with

aseptic technique from 487children 2 -9 years of age for microscopy.

vii
Results of the study revealed that malaria parasite rate was 3.9% (95% CI: 2.4-6.1) where

as fever rate and spleen rates were 9% (95% CI: 6.7-12) and 10.9% (95%CI: 8.3-14)

respectively. Household ITNs prevalence was 39%. Multivariate logistic regression

analysis was done to identify risk factors and the result revealed that family size ≤5 (p

value<0.05), child’s age 2-5 years (p value<0.05) and residing in houses with corrugated

Iron sheet roofs (p value <0.05) were found to be associated with higher risk of getting

malaria (parasite rate).

Residing in a locality called “Finchawa” (p value<0.05) and distance of settlement within

less than 1km from Lake shore of Awassa (p value<0.01) were associated with a higher

risk of malaria (spleen rate).

As the proportion of partially immune population is very low in hypoendemic areas, these

localities are prone to waves of epidemics. In areas where the option of environmental

manipulations may be difficult especially after the major rainy season, it is advisable to

apply indoor residual spraying up to a distance of 1km to effectively use scarce resources

and minimize environmental contamination. Awareness creation for the proper use of ITNs

and community mobilization is needed for environmental manipulation where possible.

Prompt diagnosis and effective treatment, as well as, where environmental manipulations

are difficult as in communities residing near Lake Awassa, Indoor residual spraying is

advised to be applied prior to the rainy season to prevent and control epidemic outbreaks.

viii
 1. Introduction

Malaria causes an estimated 300 to 500 million cases and 1.5 to 2.7 million deaths each

year worldwide and Africa shares 80% of the cases and 90% of deaths(1). Plasmodium

falciparum is by far the most aggressive species, distributed globally especially common in

Africa (1, 2).

Malaria is a leading public health problem in Ethiopia where an estimated 68% of the

population lives in malarious areas (3). In 2003 the disease was the primary cause of

reported morbidity and mortality accounting for 15.5% of out patient visits , 20% of

hospital admissions and 27% of hospital deaths(4). Malaria transmission in Ethiopia is

unstable and characterized by frequent and often large-scale epidemics (3, 5). In 2003,

large scale malaria epidemics occurred from April to December resulting in 2 million

clinical and confirmed cases and 3000 deaths, affecting 3368 localities in 211 districts(3).

Over the last five years (2001 – 2005) the proportion of malaria in out patient department,

admission and in-patient deaths has been increasing with the highest being recorded in

2003 and 2004 while a slight reduction was observed in 2005. In 2005, malaria was still

the first leading cause of health problem accounting for 48% of out patient consultations,

20% admissions and 24.9% inpatient deaths(3). It has also been documented in the

nationwide child survival study that malaria affected school attendance by 20% and

contributes to 47% of the child deaths in Ethiopia(3).

The annual average number of malaria cases reported over the period from 2001 – 2005

was 9.4 million (range 8.4 – 11.5) while the annual average number of confirmed cases

was 487,984 (range 392,419 – 591,442). In addition to this, an estimated 36% of the

1
population is out of the reach of the health service coverage. Therefore, the actual number

of malaria cases that might occur annually throughout the country is estimated to be higher

(3).

P.falciparum and P.vivax are the main species accounting for 60% and 40% of malaria

cases (6). Anopheles arabiensis is the major malaria vector followed by An. pharoensis and

other secondary vectors include An.funestus and An. nili (5, 6).

Malaria control is a big challenge due to many factors. The complexity of disease control

process, expensiveness of the control program, resistance of the parasite to antimalarial

drugs and vectors to insecticides are some of the challenges. There is a variation of disease

patterns and transmission dynamics from place to place, by season and according to

climate and environmental circumstances. The approaches in the planning and

implementation of prevention and control activities also vary based on local realities (5).

To design and implement cost effective appropriate interventions, knowledge on local

prevalence and distribution of malaria is of paramount importance. In this regard, there

was scarcity of information since there were no community based studies in Awassa

District, Sidama Zone. Hence, a cross-sectional study was carried out from February 2006

to May 2006 in Awassa District, Sidama Zone, SNNPR and the objective was to assess

prevalence of malaria and its influencing factors in the study area.

2
 2. Literature Review

Malaria morbidity and mortality

Despite Considerable progress in malaria control over the past decade, malaria remains a

serious problem particularly in Sub Saharan Africa. An estimated 300 million to 500

million cases and 1.5 to 2.7 million deaths occur world wide each year due to malaria,

and over 2400 million remain at risk(1) . In the last decade, the prevalence of malaria has

been escalating at an alarming rate, especially in Africa. One of four childhood deaths in

Africa is caused by malaria and 80% of global malarial morbidity and 90% of malarial

deaths occur in Sub Saharan Africa (1, 2).

Dramatic reductions in the annual parasite index (API) achieved by pilot IRS projects in

many parts of the world inspired the world Health Assembly to adopt malaria eradication

as a goal in 1955. However, the goal of eradication proved elusive in most malaria

endemic countries in the tropics (7, 8). A number of factors appear to be contributing to the

resurgence of malaria which include: resistance of parasite to drugs, conflicts forcing mass

migration of people to or from malaria endemic areas, migration of non– immune people to

endemic areas for agricultural reasons, changing rainfall patterns favoring mosquitoes

breeding, adverse socioeconomic conditions leading to inadequate health budget to fight

malaria, high birth rate leading to a rapid increase in susceptible population of under 5

children and changes in behavior of vectors and resistance to insecticides(9 ).

In Ethiopia, malaria stands as the leading cause of morbidity and mortality where three

quarters of the landmass is regarded as malarious and nearly 68% of the total population

live in malaria risk areas(3). In 2003 the disease was the primary cause of reported

morbidity and mortality accounting for 15.5% of out patient visits , 20% of hospital

3
admissions and 27% of hospital deaths(4). Malaria transmission in Ethiopia is unstable and

characterized by frequent and often large-scale epidemics (3, 5). In 2003, large scale

malaria epidemics occurred from April to December resulting in 2 million clinical and

confirmed cases and 3000 deaths, affecting 3368 localities in 211 districts(3).

Over the last five years (2001 – 2005) the proportion of malaria in out patient department,

admission and in-patient deaths have been increasing with the highest being recorded in

2003 and 2004 while a slight reduction was observed in 2005. In 2005, malaria was still

the first leading cause of health problem accounting for 48% of out patient consultation,

20% admissions and 24.9% inpatient deaths(3). It has also been documented in the

nationwide child survival study that malaria affected school attendance by 20% and

contributes to 47% of the child death in Ethiopia(3).

The annual average number of malaria cases reported over the period from 2001 – 2005

was 9.4 million (range 8.4 – 11.5) while the annual average number of confirmed cases

was 487,984 (range 392,419 – 591,442). In addition to this, an estimated 36% of the

population is out of the reach of the health service coverage. Therefore, the actual number

of malaria cases that might occur annually throughout the country is estimated to be higher

(3).

Changes have been observed in the epidemiology of malaria through time. Previously,

malaria was known to occur in areas below 2000m a.s.l, but currently it has been

documented to occur indigenously even in areas above 2400m a.s.l, such as Addis Ababa

and Akaki (10,11). Plasmodium falciparum is the dominant species followed by P. vivax.

These two species account for 60% and 40% of all malaria cases respectively. P.malariae

accounts only for less than 1% of cases and is restricted in distribution. P.ovale is rarely

4
reported (3). However, the relative frequency of the species varies from place to place and

from season to season. P.falciparum accounts for 69% of confirmed malaria cases in

SNNPR, while in other regions ranging from 36% in Addis Ababa to 84% in Harari(4).

P.falciparum is responsible for most, if not all, epidemics of malaria in Ethiopia. An.

arabiensis is the main vector and An. pharoensis, An. funestus and An. nili are considered

secondary vectors (5, 6).

Prevention and control

Prevention and control activities as guided by the National Strategic Plan ( 2006-2010 )

include: I) Early diagnosis and effective treatment II ) Selective vector control mainly

through the use of ITNs and IRS, III) Epidemic prevention & control IV) IEC & BCC on

malaria V) Human resource development VI) Health Management & Information System

VII) Monitoring & evaluation VIII) Operational Research (3 ) .

Physical health service coverage of Ethiopia is 64% and a significant segment of the

population does not utilize the already available health services (4). Studies have shown

that Plasmodium falciparum malaria was resistant to Sulphadoxine-pyremethamine (SP)

which had been the first line anti malarial drug for the past few years (12). This has

triggered a shift to more effective antimalarial, particularly, Artemisinin combination

therapy (ACT); now the first line treatment for uncomplicated falciparum malaria is

Artemether Lumefantrine (12). But, shortage of the new anti malarial drugs poses a

problem for prompt & effective treatment of cases in some areas. For instance, it was only

43% of the total doses needed for 2004/05 that was available in the Southern Nations,

Nationalities & Peoples' Region (13).

Chemical spray of houses is done just before the transmission season to prevent epidemics

5
and check seasonal peaks. DDT is used for indoor spraying of houses and

organophosphates use is limited to areas where DDT resistant vectors are detected. As the

trend of malaria changes over time, there should be a strong monitoring system for the

effectiveness of the insecticides used (5).

Insecticide treated nets (ITNs) are used for personal protection against malaria. Currently,

ITNs are provided at highly subsidized price or free of charge, to population groups at

higher risk such as non - immune settlers moving to malaria endemic areas, children under

five years and pregnant women(12). Estimates of ITNs coverage from a national survey

show that household ITNs possession (at least one ITN per household) was 24 %( 14).

Prevalence of malaria

Point prevalence of malaria, expressed by the parasite rate, is by far the most commonly

available measure of malaria endemicity. It has been widely used as proxy for transmission

intensity over several decades (15). The principal drawback to using parasite rate is that

they are liable to vary significantly over time, particularly in areas of unstable malaria

transmission. Some of variability associated with parasite rates can be avoided by using

spleen rates (the prevalence of enlarged spleens). These reflect chronic and latent

infections in partially immune hosts and as such provide an indication of prevailing levels

of malaria endemicity in the sample population (15, 16).

A study conducted in Khartoum has shown parasite rate of 0.21%and spleen rate of 0.17

%( 17). From cross sectional malaria prevalence surveys in Southern Mozambique,

parasite rate and spleen rate were 35.3% and 23% respectively, in the first survey( Feb

1997) and in the second survey conducted in October 1997 the parasite rate was 24.2%,

6
while, the spleen rate was 24.9% showing little variation in contrast to the parasite

rate(18). In another study conducted in Prabis, Guinea-Bissau level of malaria endemicity

determined using parasitemia and spleen rate during rainy and dry seasons revealed that

49% of villages during rainy season and 71% of villages during the dry season were

mesoendemic as measured by the parasite rate. Where as, 92% of the villages during the

rainy season and 90% of the villages during the dry season were mesoendemic as measured

by spleen rate (19).

Splenomegaly
Acute clinical episodes of malaria can cause splenomegaly which regresses after the

infection has been treated or resolved; but when malaria infections are recurrent,

splenomegaly does not regress between attacks, and a high proportion of children resident

in malaria-endemic areas have enlarged spleens (23)

Spleen examination is one of the earliest methods for estimation of the amount of malaria

in a given locality by determining the proportion of persons with palpable enlargement of

the spleen. This method has been introduced by Dempster in India in 1848 and is still

commonly used. The objective of the palpation of the spleen is to determine not only the

percentage of Spleen with lowest point palpable beyond the lower limit of class 4

individuals with demonstrable enlargement of the organ but also the approximate degree of

splenomegaly (24).

Two techniques of spleen palpation are used. In one the individual is examined lying

down, with the examiner seated on the subject’s right, so that the right hand can explore

the splenic region below the left costal margin. The second method, less cumbersome in

the field, has the subject standing, with the examiner sitting on a low stool in front of the

examined person. The examiner’s right hand gently explores the left side of the abdomen

7
from below the umbilicus towards the costal border. If no spleen is palpable, the subject is

requested to breathe deeply, while the exploring hand attempts to feel the tip of the spleen

by pressing the abdomen under the costal border (24). The proportion expressed as a

percentage) of enlarged spleens in a sample of the population is known as the spleen rate

and is a crude but nevertheless valuable measure of endemic malaria. Usually the spleen

rate is determined in children 2-10 years of age; this is because the enlargement of the

spleen is greatest when the immune response is building up.

For the determination of the degree of enlarged spleens Hackett’s method of arbitrary

classification of the size of the palpated spleen is generally accepted according to the

criteria given in the table below (24):

Classification of sizes of the spleen according to Hackett

Class of Description
spleen
0 Normal spleen not palpable even on deep inspiration
1 Spleen palpable below the costal margin, usually on deep inspiration

2 Spleen palpable below the costal margin, but not projected beyond a horizontal
line half way between the costal margin and the umbilicus, measured along a
line dropped vertically from the left nipple

3 Spleen with lowest palpable point projected more than half way to the
umbilicus but not below a line drawn horizontally through it.

4 Spleen with lowest palpable point below the umbilical level but not projected
beyond a horizontal line situated half way between the umbilicus and the
symphysis pubis

5 Spleen with lowest point palpable beyond the lower limit of class 4

8
Socio-demographic factors
Age dependence of malaria
Many studies have shown that malaria is not a common cause of death among children

under the age of 6 months and that in malaria endemic areas; very young infants rarely

contract malaria (25, 26). This protection has mainly been attributed to transplacentally

acquired malaria antibodies, as well as to other biological factors. However, after six

months of age, unprotected infants suffer repeated and severe attacks that become milder

as they grow older. A study in Nigeria; first infections were contracted during the second

half of the first year of life (26). These findings also showed that malaria parasite rates and

densities increased rapidly until the age of 6 months and thereafter decreased gradually

until one year of age. Otherwise, the proportion of infected infants increases with age, with

a tendency to plateau after the age of 4 months and the prevalence of hyperparasitaemia

(parasite density greater than 10 000 mL) also shows an increase with age over the first 6

months in an area of very high transmission intensity (27).

In all areas of high malaria endemicity, the incidence of clinical malaria is highest in young

children (under two years of age) with an average of two to six malaria attacks per year

(28) and both the incidence and the severity of the disease decreases considerably

thereafter. By the age of five years, immunoprotection is reflected by a low rate of malaria

attacks despite frequently high parasite densities (26).

Climatic and geographical parameters and malaria

Malaria is governed by a large number of environmental factors, which affect its

distribution, seasonality and transmission intensity (22)

The peak in morbidity and mortality is generally obtained in the rainy season, the time

when malaria transmission is at its peak, and the number of deaths during this period has

been shown to be over threefold higher than in the rest of the year (29).

9
The relationship between malaria vector density and the distance of a settlement from a

river is an important indicator of malaria transmission. In The Gambia ITN study, there

was an inverse relationship between the numbers of mosquitoes in a village and the

distance of settlement from the river (30)

Socio-economic parameters
Mosquito net use and malaria
A close association has been observed between people’s perception of the cause of malaria

and the type of protective measure used. In a longitudinal cohort study in Kenya, 8.5% of

women reported using a bed net regularly, 17.5% burned mosquito coils, 2.7% used an

insecticide spray, and 12.1% reported burning dung or leaves. Overall, 67% of the women

reported not taking protective measures on a regular basis, and only 5% reported using

more than one method regularly (31)

An intervention trial conducted in young children (1-9 years) in a rural area of The Gambia

to assess the impact of the traditional use of bed nets on malaria morbidity has found no

significant difference in the incidence of clinical attacks of malaria or in any other

malariometric measurements between the 2 groups of children (one group sleeping under

bed nets and the second without bed nets). Thus, bed nets were considered not very

effective in reducing malaria morbidity in this group of children (32).

On the other hand, other studies on Insecticide Treated Nets (ITN) undertaken in different

African and Asian countries have consistently documented significant reduction in the rate

of malaria parasitaemia and malaria morbidity (33, 34).

In order to plan and implement cost effective malaria prevention and control activities, the

importance of accurate information on the epidemiology of malaria is unquestionable.

10
Accordingly, there was no community based study which shows the true picture of

prevalence of malaria and its influencing factors in Awassa Woreda. Therefore, in this

study both parasite and spleen rates were used to measure prevalence and its influencing

factors in the study area.

11
 3. Objective

General Objective

To estimate prevalence of malaria and identify factors influencing it.

Specific Objectives

To estimate prevalence of malaria by spleen rate and parasitological rate.

To estimate household insecticide treated bed nets possession coverage

To identify factors that influence prevalence of malaria.

12
 4. Materials and Methods

4.1. Study area and Population

The study was conducted in Awassa Zuria Woreda of Sidama Zone; Southern Nations,

Nationalities and Peoples’ Regional State. Awassa Woreda has a population of 498,534

residing in an area of 920.8 sq km making the population density 525 people /sq km. The

rural population accounts for 75.2 % of the Woreda`s total population. The area has three

geloclimatic zones. Dega (highland > 2500m altitude a.s.l) accounts for 33%, Weinadega

(mid-land 1500-2500 m altitude a.s.l) constitutes 44% and kola (low land < 1500 m a.s.l)

accounts for the remaining 23%. The Woreda Town, Awassa, is 275 kms south of Addis

Ababa. There are 5 health centers, 29 health stations, 14 health posts, 9 pharmacies, 8 drug

shops and 25 rural drug vendors with potential health service coverage of 42.7 %. Among

ten top diseases in the District, malaria is the leading cause of morbidity and mortality

(20). The study area (Bushulo Heath center’s catchments) has 5 peasants’ associations with

a total population of 31840 and 6367 households. Localities called “Jara Damuwa” and

“Jara Gelelcha” are adjacent to each other and they have the same topography. “Jara

Damuwa” has small number of households. In this study, these two kebeles were treated as

one for analysis purposes. Therefore, the total number of localities would be four and the

common name for the above mentioned localities in this study is “Jara”.

4.2. Study Design

A cross-sectional study was conducted from February 2006 to May 2006 in Awassa Zuria

Woreda, Bushulo major health center catchment’s area to estimate prevalence of malaria

and identify factors influencing it. The study units were children age 2-9 years old drawn

from all kebeles using probability proportional to size allocation.

13
4.3. Sample size determination

The formula for calculating sample size was: n = Z (α/2)2 p (1-p)

d2
Assumptions

Based on the District data, prevalence was assumed to be 12% (21) and other assumptions

were as follows:

C.I=95% α=0.05

Precision (d) =0.03 then, the sample size (n) =451

Non-response rate (10%) = 45

Total Sample size = 496

4.4. Inclusion and Exclusion Criteria

4.4.1. Inclusion criteria

• Children age 2-9 years old residents in the area for at least two years.

4.4.2. Exclusion criteria

• Children who came from another area and lived for less than two years.

4.5. Sampling Procedures

Based on proportional to size allocation sample size of children to be drawn from each

kebele was determined. Then, by dividing the sample size to the average number of

children 2-9 years of age per household, the number of households to be selected from

each kebele was determined. Finally, simple random sampling method was employed to

select households from each kebele’s household registry using a table of random numbers.

Then, children 2-9 years of age who were members of randomly selected households were

studied.

14
4.6. Data collection

Interviewer administered semi-structured questionnaire was used to collect socio

demographic and malaria related variables. Two laboratory technicians (Diploma) and one

Health Officer were recruited & provided with two days training on the study protocol as

well as recording formats. The Health Officer examined the children for splenomegally,

took temperature readings, filled the questionnaire and prescribed antimalarial drugs for

children with history of fever (3 days duration) and or who had fever on examination as per

the National protocol.

A pretest was carried out in children (10% of the total sample size) in an area that was not

included in the main study. Based on the results, some modifications were made on the

questionnaire.

4.7. Study Variables

4.7.1. Independent

A/ Socioeconomic variables

B/ Demographic variables

C/ Malaria related variables

Household ITNs possession

Distance from the nearest health institution

Distance from mosquito breeding sites

4.7.2. Dependent

Parasitological prevalence of Malaria

Enlarged spleen prevalence

Fever prevalence

15
4.8. Data processing and Analysis

After the collection of all the necessary data, it was coded on pre arranged coding sheet by

the principal investigator. Data entry and cleaning were done using SPSS ver.10 and EPI

info.2002 statistical packages. Tables and graphs are used to present frequencies of

pertinent findings. The association between the independent and dependent variables were

measured and tested using OR and 95 % CI. The relative contribution of each selected

variables to the outcome of interest were assessed using logistic regression.

4.9. Data Quality Control

During data collection in the field and at the end of each day, the questionnaires were

reviewed and checked for completeness, accuracy and consistency by the principal

investigator and corrective measures were taken.

4.10. Ethical Consideration

Blood smears were taken under aseptic technique using sterile gloves and disposable

sterile lancets by experienced laboratory technicians. To address confidentiality of

Laboratory results, codes were used instead of names. All cases with history of fever in the

preceding three days and/or those who had fever on examination were offered antimalarial

treatment as per the National protocol.

Ethical clearance was obtained from AAU, Faculty of Medicine. After thoroughly

discussing the ultimate purpose and method of the study, a written consent was sought

from local authorities and concerned government officials. Additionally, an informed

verbal consent was obtained from parents to involve their children in the study and anyone

not wiling to take part in the study had full right to do so.

16
 5. Results
A total of 487 children 2-9 yrs of age were studied from 200 households visited in 4 rural

localities (Kebeles). From the total sample size of 496 children to be studied, parents of 6

children refused to participate and information collected from three children was

incomplete that made the response rate of 98.2%.

Socio demographic characteristics of respondents

One hundred six (53%) of household heads were in the age group 35-44years. Their mean

age was 38.7 ± 7.5 yrs and the minimum and the maximum age was 28 & 68 years

respectively (see table.1).One hundred ninety five (97.5%) of household heads were males.

Protestant Christianity was the major religion in the area accounting for 71.5% of

respondents. Majorities (98.5%) of the respondents were Sidama by ethnicity and the

same proportion was married. Most (60.5%) of the household heads had no formal

education. One hundred & thirty nine (70%) of households had family size of more than 5

persons per head. The average family size of the respondents was 6.6±1.9. One hundred &

twenty two (61%) of households had an estimated monthly family income of less than 100

ETB .One hundred & eighty one (90.5%) of mothers had no formal education.

17
Table.1. Socio demographic characteristics of household respondents,
Awassa district, 2006.

Characteristics Respondents
Number %
Age of HH head
25-34 55 27.5
35-44 106 53
45+ 39 19.5
Mean age of household 38.7±7.5
heads(years)
Sex (HH head)
Male 195 97.5
Female 5 2.5
Religion
Orthodox 3 1.5
Muslim 37 18.5
Protestant 143 71.5
Catholic 17 8.5
Ethnicity
Sidama 197 98.5
Amhara 3 1.5
Marital Status
Married 197 98.5
Widowed 3 1.5
Educational Status (HH head)
Illiterate 121 60.5
Read and Write 2 1
Primary 57 28.5
Secondary 12 6
High school 5 2.5
High school+ 3 1.5
Family size
≤5 61 30
>5 139 70
Family monthly Income
< 100 ETB 122 61
101-300 ETB 71 35.5
> 301 7 3.5
Educational Status (mother)
Illiterate 181 90.5
Read and write 1 0.5
Primary 16 8
Secondary 2 1

18
Health service and environmental factors

Travel time to the nearest Health facility on foot for the majority (71.7%) of the

respondents was less than an hour (See table 2). Seventy eight (39%) of respondents and

198(40.6%) of children 2-9 years had at least one Insecticide treated bed net per household.

Of the total 198(40.6%) study subjects who had at least one ITN per household, more than

half of them (56.1%) had never slept under insecticide treated bed net. From 83(41.5%) of

households with reported febrile cases in the previous one-month, 28(24.8%) did not visit

any health facility. With regard to housing, 398(81.7%) of children lived in houses with

thatch roof, 70(14.4%) of children lived in houses that had opening on their eaves,

393(80.7%) of children lived in houses which had no windows, 126(25.9%) of children

lived in houses with thatch wall & 278(57.1%) of children lived in houses that had

openings on their walls. Two hundred eight (42.7%) of the study subjects reside with in a

distance of less than1km from the shore of Lake Awassa. Out of the total 487 children,

276(56.7%) were in the age group of 2-5 years and females account for 50.5% of the total.

The mean number of children 2-9 years of age per household was 2.4 ± 0.9.

19
Table.2. Distribution of study subjects by selected demographic, health Service and
environmental factors, Awassa, 2006.
Characteristics Children 2-9yrs of age
Number(n=487) %
Travel time to a nearby health facility
≤1hr 349 71.7
>1hr 138 28.3
Availability of ITNs
Yes 198 40.7
No 289 59.3
Type of house roof
Thatch 398 81.7
Corrugated iron sheet 89 18.3
Presence of opening on the eave
Yes 70 14.4
No 380 85.6
Availability of windows
Yes 94 19.3
No 393 80.7
Type of wall
Mud 361 74.1
Thatch 126 25.9
Presence of opening on wall
Yes 278 57.1
No 209 42.9
Distance from shore of Lake Awassa
<1km 208 42.7
≥1km 279 57.3
Residence locality(kebele)
Alamura 136 27.9
Tulo 140 28.7
Finchawa 111 22.8
Jara 100 20.5
Age of child(years)
2-5 276 56.7
6-9 211 43.7
Sex
Male 241 49.5
Female 246 50.5
Mean number of children(2-9years) per household 2.4±0.9

20
Clinical and laboratory findings

From the total of 487 children 2-9 years, 44(9 %; 95% CI =6.7-12) had reported fever and

chills preceding three days prior to visit (see table.3.). Of these, 29(66%) had rigors and

36(82%) sweating. Twenty-seven (5.5%) of the study subjects had fever on examination as

measured by axillary’s temperature readings of ≥37.5 0C. Fifty-three (10.9%; 95% CI: 8.3-

14) children had enlarged spleen and the average spleen size was 2.26 +0.62.

Four hundred & eight-seven blood samples with thick and thin smears were collected and

examined within 12 hrs after staining with giemsa sol (10% w/w) for 10 minutes and

washing with distilled water followed by air drying. Out of the total examined slides,

malaria parasites were found in 19 (3.9%) samples, of which Plasmodium vivax accounts

for 16(84.21%) and Plasmodium falciparum for the remaining percentage (15.8%).

Table.3. Distribution of children 2-9 years by clinical presentations & Laboratory findings,
Awassa, 2006.
Clinical presentations & Laboratory results Children2-9years of age(n=487)
Number %
Fever (in the last 3 days)
Yes 44 9
No 443 91
chills
Yes 44 9
No 443 91
rigors
Yes 29 6
No 458 94
sweating
Yes 36 7.4
No 451 92.6
Axillary temperature (in degree Celsius)
≥37.5 27 5.5
<37.5 460 94.5
Splenomegally
Yes 53 10.9
No 434 89.1
Blood smear results (Plasmodium spp.)
P.falciparum 3 0.6
P.vivax 16 3.3
No haemoparasite 468 96.1

21
 The highest prevalence of microscopically confirmed malaria cases were observed in a
locality (Kebele) called “Tulo” (5% prevalence) followed by “Finchawa” (4.5%). Reported
fever prevalence was also higher for “Tulo” (12.1%) followed by “Finchawa” (11.7%)
where as, the highest splenomegally prevalence (17.1% vs. 15%) was observed in
“Finchawa” and “Jara” respectively (See Fig. 1).
Parasitological prevalence was higher in the age group 2-5 years than those in the age
group 6-9 years 5.9% and 1.4% respectively and still, reported fever was higher for the
lower age group than the higher age group (10.9 and 6.6%), respectively. Conversely,
splenomegally prevalence was a bit higher in the higher age group (11.3%) than the lower
age group (10.5%) (See Fig. 2).
Parasitological prevalence was higher in females (5.3%) than males (2.5%) whereas,
reported fever prevalence in the males was 9.1% as compared to 8.9% in females and
splenomegally prevalence was 11.2%& 10.5% in males females respectively (See Fig. 3).

18
16
14 Parasitological
12 Fever
10 Splenomegally
Percent
8
6
4
2
0
Alamura Tulo Finchawa Jara Total
Residence locality

Figure.1 Distribution of malaria prevalence by residence locality, Awassa woreda,

2006

22
 12
10
8
Percent 6 Parasitological
4 Fever
Splenomegally
2
0
2 to 5 6 to 9 Total
age ( years)

Figure.2. Distribution of malaria prevalence by age, Awassa woreda, 2006.

12

10

8
Parasitological
Percent

6 Fever
Spelenomegally
4

0
Male Female Total
sex

Figure.3 Distribution of malaria prevalence by sex, Awassa, woreda, 2006

23
Socio demographic factors and malaria
A two fold increased reported prevalence of fever was observed in children whose

parents(household heads)were in the age group of 25-34 years compared to those children

with age of their parents 35years and above(p-value<0.05). On the other hand, no

significant difference in fever prevalence was seen with other household socio

demographic characteristics (see table 4).

Table.4. Comparison of reported fever prevalence in children 2-9 years of age with
selected socio demographic factors, Awassa, 2006.
Factors Fever report in children
Yes(n=44) No(n=443) OR 95%CI P-value
Age of HH head
25-34 19 112 1
35+ 25 331 0.44 0.24, 0.84 0.012*
Educational Status (HH
head)
Non-formal 29 271 1
Formal 15 172 .82 0.43,1.56 0.540
Family size
≤5 16 103 1
>5 28 340 0.53 0.28, 1.02 0.057
Family monthly income
<100 ETB 23 262 1
≥100ETB 21 181 1.32 0.71, 2.46 0.379
Educational Status
(Mother)
Non-formal 40 396 1
Formal 4 47 .84 0.29, 2.46 0.754
Child’s age(years)
2-5 30 246 1
6-9 14 198 0.58 0.30, 1.13 0.110
Child’s sex
Male 22 219 1
Female 22 225 0.978 0.526, 1.82 0.978
*P-value < 0.05

24
The proportion of children with microscopically confirmed malaria from house holds

whose family heads in the age group 25-34years were three fold higher compared to those

children whose household heads’ age 35 years and above(P-value<0.05) (see table.5.). A

four fold increased prevalence of microscopically confirmed malaria was observed in

children with family size of five or less relative to those study subjects with family size of

greater than five (p-value<0.01) and in children with age group of 2-5years as compared to

those 6 years old and above (p-value<0.05) . Otherwise, there was no significant difference

with other socio demographic factors.

Table.5. Comparison of Malaria parasitological rate with selected socio demographic

characteristics, Awassa Woreda, 2006.
Factor Microscopically confirmed malaria in OR(95% CI) P- value
children
Yes(n=19) No(n=468)
Age of HH head
25-34 10 121 1
35+ 9 347 .314(.125,.791) .014*
Educational
status(HH head)
Non formal 13 287 1
Formal 6 181 .73(.27,1.96) .535

Family size
≤5 10 109 1
>5 9 359 .27(.11,.69) .008**
Family monthly
income
<100 7 278 1
≥100 12 190 2.5(.97,6.5) .058
Educational status (
mother)
Non formal 17 419 1
Formal 2 49 1.01(.23,4.48) .994
Child’s age(years)
2-5 16 260 1
6-9 3 208 .234(.067,.811) .023*
Child’s sex
Male 6 235 1
Female 13 233 2.2(.82,5.84) .120
*P-value<0.05
**P-value<0.01

25
As depicted in table 6, spleen rate didn’t show a significant difference with all the selected

socio demographic factors.

Table.6. Comparison of enlarged spleen prevalence in children 2-9yrs with selected socio
demographic factors, Awassa Woreda, 2006.
Factors Enlarged spleen in children OR (95%CI) P-value

Yes (n=53) No (n=434)

Age ( HH head)
25-34 14 117 1
35+ 39 317 1.025(0.54, 1.96) 0.940
Educational Status
(HH head)
Non formal 33 267 1
Formal 20 167 .97(.54, 1.75) 0.916
Family size
≤5 22 149 1
>5 31 286 0.898(0.47, 1.72) 0.744
Family monthly income
< 100 30 255 1
≥ 100 23 179 1.09(0.61, 1.94) 0.764
Educational status
(mother)
Non formal 49 387 1
Formal 4 47 .672(0.232, 1.95) 0.640
Child’s age(years)
2-6 29 247 1
7-9 24 187 1.05(0.575, 1.92) 0.874

Child’s sex
Male 27 214 1
Female 26 220 0.93(0.53, 1.65) 0.810

Health service and environmental determinants of malaria

Reported fever prevalence was 2.6 times higher in a locality called “Tulo” compared to

“Alamura” (P-value< 0.05) and 2.5 times higher in “Finchawa” compared to “Alamura”

though it had no significant association (P-value > 0.05) as shown in table 7. Prevalence of

reported fever has not showed a significant difference with household availability of

insecticide treated bed nets (p-value>0.05). Study subjects living at a distance of less than

1km from shore of Lake Awassa had shown 1.7 times higher prevalence of fever compared

26
to those residing at a distance of ≥1km away from Lake Shore, though the difference was

not statistically significant (P-value > 0.05).

Table.7. Comparison of reported fever prevalence in children 2-9 years of age by health
service and environmental factors, Awassa Woreda, 2006.
Fever report in children
Factors Yes(n=44) No(n=443) OR (95%CI) P-value
Residence
Alamura 7 129 1
Tulo 17 123 2.54(1.03, 6.4) 0.045*
Finchawa 13 98 2.46(0.95, 6.4) 0.067
Jara 7 93 1.4(0.47, 4.1) 0.554
Travel time to the nearby health facility
<1 hour 31 318 1
≥1 hour 13 125 1.07(0.54, 2.1) 0.845
ITN availability
Yes 21 177 1
No 23 266 0.73(0.39, 1.35) 0.313
Type of house roof
Thatch 34 364 1
Iron sheet 10 79 1.36(0.65, 2.87) 0.425
Opening on the eave
Yes 7 63 1
No 37 381 .874(0.37, 2.05) 0.761
Availability of window
Yes 9 78 1
No 35 366 0.793(0.37, 1.67) 0.547
Type of wall
Mud 30 332 1
Thatch 14 112 1.38(0.71, 2.7) 0.342
Opening on the wall
Yes 24 255 1
No 20 189 1.1290.6, 2.09) 0.721
Distance from lake shore
≥1 K.M. 24 184 1
<1 K.M. 20 260 1.69(0.91, 3.15) 0.099
*P-value <0.05

As presented in table 8, parasite rate of malaria has shown nearly a three fold increase in

children who lived in houses with roofs that had corrugated Iron sheet compared to those

children who lived in houses with thatch roofs (p-value <0.05). Even though the difference

was not statistically significant ,2.6 times increase in parasite rate was observed in children

who lived in houses that had windows compared to those children who lived in houses

27
 with no windows(p-value>0.05). Otherwise, no significant differences were observed with

differences in residence localities, neither household availability of ITNs nor distance

variation of settlement from the Lake Awassa (p-value>0.05).

Table.8.Comparison of Malaria parasitological prevalence in children 2-9years with

selected health service and environmental factors, Awassa Woreda, 2006.

Factor Microscopically confirmed OR(95% CI) P -value

malaria in children
Yes(n=19) No(n=468)
Residence
Alamura 4 132 1
Tulo 7 133 1.74(.50,6.10) .387
Finchawa 5 106 1.56(.41,5.98) .517
Jara 3 97 1.02(.22,4.70) .979
Travel time to nearby heath facility
<1 hour 13 336 1
≥1 hour 6 132 1.18(.44,3.16) .749
ITN availability
Yes 10 188 1
No 9 280 .60(.24,1.51) .283
Type of roof
Thatch 12 386 1
Iron 7 82 2.75(1.05,7.20) .040*
sheet
Opening on the eave

Yes 3 67
No 16 401 .89(.25,3.13) .858
Availability of window
Yes 7 87 1
No 12 381 .39(.15,1.02) .056
Type of wall
Mud 13 348 1
Thatch 6 120 1.34(.499,3.61) .564
Opening on the wall
Yes 9 269 1
No 10 199 1.50(.60,3.77) .386
Distance from lake shore
≥1 K.M. 9 271 1
<1 K.M. 10 198 1.50(.60,3.77) .376

*P-value<0.05

28
On the other hand, the scenario was different with spleen rate in that, significant

differences in enlarged spleen prevalence were observed between residence localities, with

variation in distance of settlement from shore of Lake Awassa, and by differences with

travel time to the nearest health institution. Compared to a locality called ‘Alamura’,

those children living in ‘Tulo’ had a 9 fold increased spleen rate (p-value<0.01), those

living in ‘Finchawa’ had 13 fold increase (p-value<0.01 and children in “Jara” had 11 fold

increased prevalence (P-value < 0.01) (see table 9).

Travel time elapsed for parents to reach the nearest health facility on foot more than an

hour had shown nearly a 3 fold increased prevalence of enlarged spleen in children

compared to those children whose parents walk only an hour or less to reach the nearest

health facility (P-value < 0.01). In addition, children living within a distance of less than

1km from shore of Lake Awassa had shown 5 times increased prevalence of enlarged

spleen (P-value<0.001). But, availability of household ITNs didn’t show a difference (P-

value > 0.05).

It was reported that indoor residual spraying had not been applied in all the study localities

at least in the past one year prior to the study; therefore, it was omitted from further

analysis.

29
 Table.9. Comparison of enlarged spleen prevalence with selected health service and
environmental factors, Awassa Woreda, 2006.
Factor Enlarged spleen in children OR(95% CI) P value
Yes(n=53) No(n=434)
Residence
Alamura 2 134 1.00
Tulo 17 123 9.21(2.09,40.54) .003**
Finchawa 19 92 13.76(3.14,60.74) .001**
Jara 15 85 11.76(2.63,52.54) .001**
Travel time to nearby
facility
<1 hour 27 322 1
≥1 hour 26 112 2.77(1.55,4.94) .001**
ITN availability
Yes 21 177 1
No 32 257 .95(.53,1.71) .871
Type of house roof
Thatch 41 357 1
Iron sheet 12 77 1.36(.68,2.70) .385
Opening on the eave
Yes 3 67 1
No 50 367 .33(.10,1.08) .068
Availability of window
Yes 12 82 1
No 41 352 .796(.40,1.58) .515
Type of wall
Mud 35 326 1
Thatch 18 108 1.56(.85,2.85) .157
Opening on the wall
Yes 30 248 1
No 23 186 1.02(.57,1.82) .940
Distance from Lake
shore
≥1 K.M. 13 266 1
<1 K.M. 40 168 4.87(2.53,9.38) .000***
**P-value<0.01

**P-value<0.0001

30
Multivariate Logistic regression analysis results
All socio demographic, health service and environmental factors that showed significant

associations with malaria prevalence in univariate analysis were selected and entered for

multivariate logistic regression analysis to identify the most important predictors of

malaria risk factors.

Then, the result showed that reported fever prevalence in “Tulo’ and “Finchawa” was two

fold higher compared to “Alamura” but it was not statistically significant (p-value>0.05)

and all other factors also didn’t show significant associations (see table 10).

The same independent variables were entered in analysis for parasite rate and spleen rate.

Then, the result revealed that family size ≤5 (p value<0.05), child’s age 2-5 years (p

value<0.05) and residing in houses with corrugated Iron sheet roofs (p value <0.05) were

found to be associated with higher risk of getting malaria (parasite rate) as presented in

table 11.

Residing in a locality called “Finchawa” (p value<0.05) and distance of settlement within

less than 1km from Lake shore of Awassa (p value<0.01) were associated with a higher

risk of malaria (spleen rate) as depicted in table 12.

31
Table.10. Multivariate Logistic regression analysis of reported fever prevalence in children
2-9 years of age by socio demographic and environmental factors, Awassa, 2006.
Fever in
children
Factors Yes No β SE OR (95%CI) p- value
Residence
Alamura† 7 129
Tulo 17 123 .600 .600 1.82(.63,5.24) .266
Finchawa 13 98 .717 .576 2.05(.66,6.34) .213

Jara 7 93 -.192 .780 .825(.179,3.81) .805

Age(HH head)
25-34† 19 112
35+ 25 332 -.573 .377 .564(.269,1.18) .129
Family size

< 5† 16 103
>5 28 340 -.473 .387 .623(.292,1.33) .222
Travel time to nearby health
facility
<1hr† 31 318
≥1hr 13 125 .208 .620 1.23(.366,4.15) .737
Type of house roof

Thatch† 34 364
Iron sheet 10 79 .288 .424 1.33(.581,3.08) .497
Child’s age (years)

2-5† 30 246
6-9 14 197 -.499 .348 .607(.307,1.20) .151
Distance from lake shore
≥1 km† 24 184
<1 km 20 259 .488 .431 1.63(.699,3.79) .259
Constant -2.111 .460 .061 .000
†Reference category
Model chi-square=17.259 P-value=0.045

-2Log Likelihood=278.199

32
 Table.11.Multivariate logistic regression analysis of Malaria parasitological rate with
selected socio demographic and environmental factors, Awassa Woreda, 2006.
Microscopically confirmed
malaria in children

Factor Yes(n=19) No(n=468) β SE OR(95% CI) P- value

Residence
Alamura 4 132
Tulo 7 133 .147 .768 1.16(.26,5.22) .848
Finchawa 5 106 .058 .915 1.06(.177,6.37) .949
Jara 3 97 -1.052 1.21 .349(.033,3.74) .384
Age(HH head)
25-34† 10 121
35+ 9 347 -.504 .542 .604(.209,1.75) .352
Family size
≤5† 10 109
>5 9 359 -1.29 .564 .275(.091,.830) .022*
Travel time to nearby health
facility
<1hr 13 336
≥1hr 6 132 .935 1.023 2.55(.343,18.92) .361
Type of roof
Thatch† 12 386
Iron sheet 7 82 1.381 .588 3.98(1.26,12.60) .019*
Child’s age(years)

2-5† 16 260
6-9 3 208 -1.461 .658 .232(.064,.843) .026*
Distance from lake shore
≥1 km† 9 270
<1 km 10 198 .288 .669 1.33(.36,4.94) .667
Constant -2.320 .590 .000
†Reference category
*P value <0 .05
Model Chi-square = 23.353 and P- value =0.005
- 2 log likelihood = 137.162

33
 Table.12.Multivariate logistic regression analysis of enlarged spleen prevalence in
children with selected socio demographic and environmental factors, Awassa Woreda,
2006.
Enlarged spleen in children
2-9yrs
Factor β SE OR(95% CI) P- value
Yes(n=53) No(n=434)
Residence
Alamura† 2 134
Tulo 17 123 1.554 .815 4.73(.96,23.36) .057
Finchawa 19 92 1.868 .822 6.47(1.29,32.41) .023*
Jara 15 85 1.054 .915 2.87(.477,17.24) .249
Age(HH head)
25-34† 14 117
35+ 39 317 .241 .389 1.27(.593,2.73) .536
Family size
≤5† 14 105
>5 39 329 -.515 .382 .597(.280,1.26) .177
Travel time to the nearby health
facility
≤1hour† 27 322
>1 hour 26 112 .406 .539 1.50(.522,4.32) .451
Type of roof
Thatch† 41 357
Iron sheet 12 77 .345 .398 1.41(.647,3.08) .386
Child’s age(years)

2-5† 29 247
6-9 24 187 .047 .311 1.05(.570,1.93) .880
Distance from lake shore
≥1km† 13 266
<1km 40 168 1.118 .416 3.06(1.35,6.92) .007**
constant -4.100 .785 .000
†Reference category
*P-value < 0.05 **P-value<0.01
Model Chi-square = 38.57 and P-value = 0.000
- 2 log likelihood = 296.546

34
 6. Discussion
The results of this study revealed that malaria parasite rate was 3.9% (95% CI: 2.4-6.1)

where as fever rate and spleen rate were 9% (95% CI: 6.7-12) and 10.9% (95%CI: 8.3-

14) respectively. The explanation for the difference between spleen rate and parasite rate

is that spleen rate is a relatively stable measure of malaria prevalence, which does not

significantly vary, with seasonal fluctuations of malaria prevalence as opposed to parasite

rate that fluctuates with seasonal variations in intensity of malaria transmission (15, 16).

This cross-sectional study was conducted during the dry season when the intensity of

malaria transmission is expected to be lowest compared to the major and minor

transmission periods (following the major rainy season (“kiremt”) and the minor rainy

season (“Belg”). The parasite rate indicates the dry season prevalence while the spleen

rate indicates the prevailing annual malaria prevalence of the area (15, 16, and 29).

Household ITNs possession prevalence was 39% which is relatively higher than the

National coverage (24%) (14).

Several studies indicate that the use of insecticide treated bed nets significantly reduce

the proportion of malaria morbidity and mortality in children1-10yrs (33, 34). To the

contrary, some studies conducted in African countries revealed that the use of ITNs

didn’t show a significant difference in malaria morbidity and mortality in children 1-

10yrs of age (32). In line with this, a difference was not observed in malaria prevalence

among ITNs users and non-users in this study as demonstrated by fever, parasite as well

as spleen rate with multivariate logistic regression analysis. The mere presence of ITNs in

households may not protect children from Malaria morbidity unless it is properly used

that could also be the implication of this finding.

Malaria is governed by a number of environmental, socio demographic and economic

factors, which affect its distribution, seasonal occurrence and transmission intensity (22).
35
Among the socio demographic factors, studies indicate that malaria morbidity and

mortality in children under the age of 5 yrs of age is higher compared to children above

five years old. In agreement with this, the result of this study shows a four fold increased

parasite rate in children 2-5 yrs of age compared to those children 6-9 yrs old (P-value <

0.05) (25,26). The other socio demographic factor which showed a significant association

was house hold size < 5 that revealed a 4 fold increase in percentage of malaria

cases(parasite rate) compared to family size above 5 (P-value < 0.05).

From environmental factors, area of residence has shown a significant association (P-

value < 0.05). Namely two localities (‘Tulo’ and ‘Finchawa’) have showed higher

prevalence of fever compared to ‘Alamura’ and ‘Finchawa’ has also showed a higher

prevalence of spleen rate compared to ‘Alamura’ (P-value < 0.05). Studies also witness

that the relationship between malaria vector density and the distance of settlement from a

water body like river is an important indicator of malaria transmission, as revealed in

ITNs study in Gambia, they found out an inverse relationship between the number of

mosquitoes in village and the distance of settlement from the river (30). This study also

showed that spelnomegally prevalence had a three fold increase in those children residing

within a distance of less than 1km form the shore of ‘Lake Awassa’ compared to those

residing 1km further away from the Lake shore of Awassa (P-value < 0.01). Some studies

indicate physical access like distance to health service was a determinant factor for

malaria. In this study, though distance variation to the nearest health facility had shown

significant association with prevalence of malaria with univariate analysis, it lost its

significance with multivariate logistic regression analysis.

36
 Strengths and limitations

Strengths

Two measures (spleen rate & parasite rate) were used to estimate the prevalence

of malaria.

Simple random sampling was used

Limitations

As any cross-sectional study, it is difficult to establish a causal relationship in

this study.

Household ITNs prevalence was studied but knowledge, attitude and practice

about ITNs use and application was not included.

The study was conducted during dry season, when the parasitological yield is

expected to be low.

Conclusions

Though house hold prevalence of ITNs was relatively higher than the national one

(39% Vs 24%), more than half a proportion of children were not sleeping under it. This

provides a clue for improper use of bed nets that needs further exploration and design

strategies to improve its appropriate use.

The result of this study showed that the area in general could be classified as

hypoendemic as demonstrated by spleen rate of 10.9% (95% CI. 8.3 – 14) but among the

four localities “Finchawa” can be classified as mesoendemic area.

37

In general; Residing in “Finchawa”, Age < 5 yrs, Distance of settlement <1km

from the Lake shore of Awassa, and Household size < 5 were the risk factors identified in

this study.

Recommendations

In areas where the option of environmental manipulations may be difficult

especially after the major rainy season, it is advisable to apply indoor residual spraying

up to a distance of 1km to effectively use scarce resources and to minimize

environmental contamination.

Children especially those under 5 years of age should be given due emphasis for

prompt diagnosis and effective treatment as well as increased use rate of ITN.

Proper awareness creation for appropriate utilization of ITNs.

Community mobilization for environmental manipulation where possible.

As well as, where environmental manipulations are difficult as in communities

residing near Lake Awassa Indoor residual spraying is advised to be applied prior to the

rainy season to prevent and control epidemic outbreaks.

38
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42
 Annexes
Annex 1: Questionnaire for data collection
Questionnaire No
ADISS ABABA UNIVERSITY
MPH RESEARCH PROJECT
ON
PREVALENCE OF MALARIA
Part I- Socioeconomic status of households
101.Name of Kebeles
1.Alamura 2. Tulo 3. Finchawa 4. Jara Damuwa 5. Jara Gelelcha

102.ID No of Household head

103.Age of Household head

104.Sex of household head

1. Male 2. Female
105.Religion
1. Orthodox 3.protestant
2. Moslem 4. Catholic 5. Other specify
106. Ethnicity
1. Sidama
2.Wolaita
3. Amahara
4. Oromo
5. Others Specify

107. Marital status

1. Single
2.Maried
3. Divorced
4. Widowed
108. Educational status of house hold head
1. Illiterate
2. Read and write
3. Primary school
4. Secondary school
5. High school
6. Above high school

109. Household size

110. Number of children 2-9years of age in a house hold

111. House hold income in a month

1. <100birr
2. 101-300birr
3.301-500bir
4. >500birr

112. Educational status of spouse

1. Illiterate 2. Read and write 3. Primary school 4. Secondary school
5. High school 6. Above high school 7. NA

43
 Questionnaire No
Part II - Malaria related questions and observations
201. How long does it take to reach the nearest health institution on foot?
1. <15 minutes
2. 15-30 minutes
3. 30-45minutes
4. 45-60 minutes
5. >l hr
202. Is there insecticide treated bed net in the household?
1. Yes
2. No… skip to No 205
203. If yes how many ITNs do you have? 1. 01
2. 02
3. 03 4. >3
204. Who uses the ITNs? 1. Children only 2.mother only 3. Father only 4.
Father and mother only 5. The whole family 6.Children and mother

205. Is there any one in the family who had fever with in the last month?
1. Yes
2. No

206. If yes, Where did you go for treatment?

1. Drug vendor
2. Health center
3. Health post
4. Health station
5. Hospital
6. Traditional healers
7. No where (managed at home)
207. Distance of the nearest health institution?
1. <5km
2. 5-10km
3. >10km
208. Type of house roof?
1. Thatch
2. Corrugated Iron sheet
3. Mud
4. Other specify

209. Is there an opening on the eave?

1.Yes
2.No

210. Number of windows available?

1. 0
2. 1
3. 2
4. ≥3

Questionnaire No
44
211. Type of wall
1. Mud
2. Thatch
3.Other
212. Is there an opening on the wall?
1. Yes
2.No

213. Distance of the house from lake shore

1. <1km
2. 1-3km
3. 3-5km
4. >5km

214. Was the house sprayed with insecticide in the last 6 months?
1. Yes
2. No skip to part III

215. If yes, what type of insecticide was sprayed?

1.DDT
2.Malathion
3.others specify

216. When was last sprayed?

1.3 months back
2. 6 months back
3.other specify_____________

45
 Questionnaire No__________

HH Head ID No_________

Child ID No____________

Part III. Clinical History and Examination

301. Age of the child in completed years

302. Sex of the child 1.Male 2. Female

303. Does the child have history of fever in the last 3

days? 1. Yes 2. No

304. Does the child have chills? 1. Yes 2. No

305. Does the child have rigors? 1. Yes 2. No

306. Does the child have sweating? 1. Yes 2. No

307. Spleen size 1. Class I 2. Class II 3. Class III 4.

Class IV 5. Class V

308. Temperature in degree Celsius

1. <37.5 2. ≥ 37.5

309. Laboratory diagnosis

1. P. Falciparum 2. P. Vivax 3. Mixed infection 4. No
haemoparasite 5. Other specify

46
Annex 2: Laboratory results reporting format

Laboratory results reporting format

S.NO Kebele H.H Child Blood Film Result
ID ID No 1. P.F 2.P.V 3.Mixed 4.NO 5.Other Remark
NO H/P
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

Remark:
kebeles
1. Alamura
2. Tulo
3. Finchawa
4. Jara Damuwa
5. Jara Gelelcha

47
Annex 3: Consent Form

Addis Ababa University

Faculty of Medicine
Department of Community Health

CONSENT OF THE INTERVIEWEE

Hello? I am ………………………..from AAU, I am here with my colleagues to study

about Malaria in children 2-9yrs old. We will ask you some questions related to malaria

and examine your children for signs of malaria and will take blood smear to examine for

malaria parasites. Please be assured that the information will be confidential since we do

not register names and you may choose to stop your child’s/children’s participation or

refrain from answering any question at any time. If you decide not to participate, your

care here will not be affected.

At this time do you want to ask me any thing about this study?

Do I have your agreement to participate ____________ (yes or no?)

Signature_____________

48