THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND

CHILDREN
TANGANYIKA MEDICAL TRAINING BOARD
ORDINARY DIPLOMA IN PHARMACETICAL SCIENCE
TABORA (EA) POLYTECHNIC COLLEGE

(NTA LEVEL 6)
(SEMESITER TWO)

TITLE: ASSESSING MALARIA CASE MANAGEMENT AMONG CHILDREN UNDER

FIVE YEARS OF AGE ATTENDING HEALTH FACILITIES IN NZEGA DISTRICT.

NAME OF RESEARCHER BICHURO EMANUEL GWAMIYE

REGISTRATION NUMBER NS.3461/0038/3018

MODULE NAME OPERATIONAL RESEARCH
RESEARCH INSTRUCTOR NAME PHARM. BURHANI ISMAIL SAID
PHONE NUMBER. 0621212625

SUPERVISOR NAME PHARM. ERASTO MURUNGU.

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Contents
ACKNOWLEDGEMENT..................................................................................................................................................3
LIST OF ABBREVIATIONS.............................................................................................................................................. 4
ABSTRACT.................................................................................................................................................................... 5
WORKING DEFINITIONS...............................................................................................................................................6
1.0 INTRODUCTION......................................................................................................................................................7
1.1 BACKGROUND INFORMATION...........................................................................................................................7
1.2 PROBLEM STATEMENT...................................................................................................................................9
1.3 RATIONALE.......................................................................................................................................................10
1.3.1 HYPOTHESIS..............................................................................................................................................10
1.4 STUDY OBJECTIVES...........................................................................................................................................10
1.4.1 Broad objective.......................................................................................................................................10
1.4.2 Specific objectives....................................................................................................................................10
1.5 RESEARCH QUESTIONS...............................................................................................................................10
1.6 Variables Dependent variables:........................................................................................................................11
2.0 LITERATURE REVIEW............................................................................................................................................12
3.0 METHODOLOGY...................................................................................................................................................15
3.1 Study design.....................................................................................................................................................15
3.2 Study area........................................................................................................................................................15
3.3 Study population..............................................................................................................................................15
3.4 Sample size estimation.....................................................................................................................................15
3.5 Sampling technique and sample selection.......................................................................................................15
3.5 Data collection procedure................................................................................................................................16
3.5.1 Pre-testing.................................................................................................................................................16
3.5.2 Data collection..........................................................................................................................................16
3.6 Specimen collection and processing.................................................................................................................17
3.7 Data analysis....................................................................................................................................................17
3.8 Ethical consideration........................................................................................................................................17
3.9 Study limitation................................................................................................................................................18
3.9.1 Data collection tool......................................................................................................................................18
4.0 WORK PLAN......................................................................................................................................................... 19
5.0BUDGET.................................................................................................................................................................20
REFERENCE.................................................................................................................................................................21
APPENDEX..................................................................................................................................................................22

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ACKNOWLEDGEMENT
This dissertation could not have been completed successfully had it not been for the valuable
contributions I received from a number of people including members of academic staff of the
School of Public Health, Tabora polytechnic college, Tabora..

First of all, I would like to acknowledge the immense assistance I received from my supervisor,
pharm. Erasto Murungu who devoted much of his time in going through and shaping the
research plan at various stages. His constructive criticisms and comments were of enormous
assistance at all stages of the development of this dissertation

I am similarly grateful to all the in-charges and staff of the health care facilities in Nzega
District where research for this dissertation was conducted.

I cannot forget to acknowledge the support and advices I received from my friends, Mr and Mrs
Lugano Daimon, Joyce Protas, Simon Chaula and Sadru Green. Support from my husband
should also be put on record who took great care of our daughter Sengekirose while I was away.

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LIST OF ABBREVIATIONS
ACTs Artemisinin based Combination Therapies
ALu Artemether-Lumefantrine
CRF Case Report Form
DMO District Medical Officer
ECM Effective Case Management
HCWs Health care workers
IMCI Integrated Management of childhood illness
MCM Malaria Case Management
MoHSW Ministry of Health and Social Welfare
MRDDs Malaria Rapid Diagnostic Devices
mRDTs Malaria Rapid Diagnostic Tests
NMCP National Malaria Control Programme
Pf-HRP-2 Plasmodium falciparum Histidine Rich Protein- 2
PH Power of Hydrogen ion
SP Sulfadoxine-Pyrimethamine
SSA Sub-Saharan Africa
VHWs Village Health Workers
WHO World Health Organization

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ABSTRACT
Background
Malaria is still a major public health problem in Tanzania. Due to this, the Ministry of Health
and Social Welfare has developed guidelines for malaria case management. The main goal of the
guidelines in the country is to attain uniformity and rational use of Antimalarials in malaria case
management.
The current guidelines specifically emphasize the use of parasitological confirmatory test using
mRDTs or microscopy before taking the recommended ACTs.

5
WORKING DEFINITIONS
In this study unless specified otherwise herein under or context demands a contrary meaning:
“Assessing” means the process of collecting and analyzing relevant information that will be
relied on for decision making;
“Malaria” means a parasitic disease caused by Plasmodium, which is transmitted through the bite
of infective female Anopheles mosquito.
“Malaria case management” refers to the process of, first, identifying patients who may be
suffering from malaria, by diagnosing them through parasitological confirmation either by using
a microscope or the mRDTs and, secondly, provision of the anti- malarial drugs as
recommended by the National Guidelines for Malaria Diagnosis and Treatment of Tanzania;
“Guidelines” means the National Guidelines for Malaria Diagnosis and Treatment issued by the
Tanzania Ministry of Health and Social Welfare in 2006.
“Health facilities” means dispensaries, health centre and the District hospital or any entity of
whatever description that provides health care.
„„Medications‟‟ refers to Antimalarial given to the child, Antibiotics, Antipyretics and other
available drugs at the health facility.
„„Parasitological confirmation‟‟ refers to testing the child by either using Microscope or
mRDTs.
„„Fever‟‟ refers to feeling the child‟s body hot.
„‟In the study fever‟‟ refers to measured body temperature ≥37.50C
“Correct treatment‟‟ refers to patients tested for malaria and treated with ALu if the test results
were positive or not treated for malaria if the test results were negative.

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1.0 INTRODUCTION
1.1 BACKGROUND INFORMATION
Malaria means a parasitic disease caused by Plasmodium, which is transmitted through the
bite of infective female Anopheles mosquito
Malaria parasites belong to the genus Plasmodium. The parasites belong to the phylum
apicomplexa which is the name given for their possession of an apical complex. There are
approximately 156 named species of Plasmodium which infect various species of vertebrates –
four are known to infect humans: Plasmodium falciparum; Plasmodium vivax; Plasmodium
malariae and Plasmodium ovale.
Among the four species that infect humans; Plasmodium falciparum and Plasmodium vivax
account for 95% of infections. Globally Plasmodium vivax has the widest distribution that
extends throughout the tropics, sub-tropics and temperature zones; while Plasmodium falciparum
is generally confined to the tropics. On the other hand Plasmodium malariae is rarely distributed,
and, Plasmodium ovale is confined mainly to Central West Africa and some South Pacific
Islands. Of all the malaria parasites; Plasmodium falciparum have been found to cause severe
malaria, and the reason for this is delay in treatment (Tangpukdee, 2009). The population groups
most at risk are pregnant women, mostly affecting primigravidae and children who are under five
years of age (WHO, 2010). The main reason for this is that the pregnancy reduces woman
immunity to malaria making her more susceptible to malaria infection and increases the risk of
illness, severe anaemia and death. In children under five years the reason is due to their lowered
immunity (WHO, 2010).
In these groups malaria has been reported to cause deaths, low birth weight, still birth and
anaemia (WHO, 2010; MoHSW, 2006).
Global Malaria Situation
Malaria is still a major global health problem and one of the leading causes of mortality and
morbidity. To date, malaria remains an important public health problem globally with 3.3 billion
people at risk. Each year an estimated 300 million to 500 million people have been reported to
become ill with malaria (WHO, 2010). In 2010, an estimated 216 million cases and 655,000
deaths due to malaria occurred worldwide. Of these, about 81% of the cases and 91% of the
deaths were reported from the African Region – mostly affecting children under five years and
every 30 to 45 seconds, an African child dies of malaria (WHO, 2011). Consequently, malaria
remains to be one of the major causes of deaths among young African children (WHO, 2010).
Besides, malaria accounts for 20% of all childhood deaths.
Economically, malaria causes an annual loss of $12 billion which accounts for approximately 40
percent of public health expenditures in Africa (WHO, 2010). Since the year 2000, malaria
control efforts have increased globally. As a result there is growing evidence now documenting a
substantial decline in malaria transmission, morbidity, and mortality in many countries including
Tanzania.

7
Studies done in different parts of Africa indicate that, the malaria epidemiology is changing. For
example in Tanzania the prevalence of malaria among children under five years in 2007 – 2008
was 18%, but in 2012 the prevalence has decreased to 10% as measured by mRDTs and with
microscopy is 4%. The main reason for this reduction is due to large scaling up of integrated
malaria control strategies including Effective Malaria Case management by using ACTs, Indoor
Residual Sprays (IRS) and the use of LLITNs (NMCP. 2012).
The burden of Malaria in Tanzania
Malaria is the single most significant disease in Tanzania affecting the health and welfare of its
mainlanders, 43,625,434 million inhabitants according to the 2012 population and housing
census. In Tanzania, malaria remains to be the leading cause of high morbidity and mortality as it
accounts for 40% of all out-patient attendances (Rugemalila et al., 2006). It is responsible for
more than one-third of all deaths, 39.4% of all health care visits, and 33.4% of all hospital
admissions among children under the age of 5 years (Mboera et al., 2007). The overall
prevalence of malaria in young children, aged 6 to 59 months, in Tanzania as measured by the
mRDTs is 10% and with microscopes is 4%. The highest malaria prevalence among children is
found in Geita (33 percent); followed by Lindi, Kigoma and Mara, 26 percent each. The regions
with the lowest malaria prevalence among children under five are Arusha, Kilimanjaro, Singida
and Iringa (NMCP, 2012).
Nzega district is found in Tabora, a region located in the western part of Tanzania. In 2011, the
population of Nzega district was 507,992 inhabitants (MTUHA, 2011). In the same year, the
total out-patients among children under five years were 222, 237. Out of that figure, 43,665 were
malaria positive which, unfortunately, resulted in 97 deaths. The majority of these cases were
clinically diagnosed (MTUHA, 2011).
However, according to a 2010 study malaria epidemiology in Tanzania is changing (Mmbando et
al., 2010). In the study, results showed that the prevalence of malaria parasitaemia decreased in
lowland villages of Tanzania from 78.4% in 2003 to 13.0% in 2008 and in highland villages
from 24.7% to 3.1% in the same period studied. This decrease was associated with the use of bed
nets (LLITNs) with a P value of < 0.001. Also the decrease in prevalence has been observed in
other parts of Sub-Saharan Africa (O‟Meara et al., 2010). Generally in Africa, the decline is
attributable to intensified control efforts, particularly; the use of more effective anti-malarial
drugs ACTs, scaling up effective use of Insecticide Treated Nets, and Indoor Residual Spraying.
Malaria Case Management
This refers to the process of first identifying patients who may be suffering from malaria, by
diagnosing through parasitological confirmation either by using a microscope for the detection of
parasite in the blood or the mRDTs, and provision of the anti-malarial drugs as recommended by
the National Guidelines for Malaria Diagnosis and Treatment. The major components of the
clinical process for malaria case management involves: clinical assessment, which includes
history taking and clinical examination; diagnosis, including the classification of malaria and the
use of laboratory support; effective treatment; and adequate counseling and drug dispensing
(Zurovac, 2005). Accurate diagnosis is fundamental for effective malaria treatment.

8
Traditionally in clinical practice, a case of malaria is confirmed upon microscopic demonstration
of Plasmodium parasites in a patient presenting with the clinical features of the disease – the
most important hallmark being fever. However, in Africa, especially at the periphery of the
health care system, microscopic support for malaria diagnoses is not available and malaria is
routinely diagnosed on observable clinical symptomatic bases. These problems with malarial
diagnoses have also been observed in Tanzania (Font et al., 2001; and Nsimba et al., 2002).
Now there is increasing malaria control efforts like the use of mRDTs, LLITNs and IRS in
different settings of Africa including Tanzania, this has lead to documenting evidence which
indicates that there is a substantial decline in malaria transmission (D‟Acremont et al., 2009).
Due to this decline there is a need for treating an individual who is parasitologically confirmed to
have the disease.
In Tanzania we have the current National Guidelines for Malaria Diagnosis and Treatment. The
main goal of the guidelines is to attain uniformity in malaria case management in the country.
The current guidelines were formulated in 2006 in which ACTs, in the form of ALu, was
recommended. The 2006 Guidelines for malaria diagnosis and treatment were revised in 2010.
Under the revised version, the Guidelines specifically emphasize on the use of parasitological
confirmatory test using the mRDT or microscopy across all age groups before taking the
recommended ACTs (NMCP, 2012). These new recommendations have been adopted in the
country.
Therefore this study aims at assessing malaria case management among children under the age of
five years attending health facilities in Nzega district, Tanzania, as per the National Guidelines
for Malaria Diagnosis and Treatment.
1.2 PROBLEM STATEMENT
Malaria is a significant public health problem in Tanzania. Due to this the Ministry of Health and
Social Welfare (MoHSW) has developed guidelines for malaria case management. These
guidelines are revised regularly based on evidence and changes in recommended anti-malarial
drugs and, also, changes in epidemiological patterns. The current guidelines were formulated in
2021 in which ACTs in the form of ALu was recommended. The National Guidelines for malaria
diagnosis and treatment were revised again in 2010. In this new revision, the guidelines
specifically emphasize on the use of parasitological confirmatory test using the mRDT or
microscopes across all age groups before taking the recommended Artemisinin-based
Combination Therapy (NMCP, 2012). Despite the presence of these guidelines little is known
about how well they are being implemented on the ground at the health facility level (Mugoyela
and Minzi, 2011). Also there is growing evidence that malaria guidelines in most of the African
countries are not being followed strictly. In Angola a study on assessing the quality of malaria
case management at outpatient health facilities, showed that health care providers were not
adhering to the recommended guidelines for malaria case management whereby 45.6% of the
patients were given the ACTs unnecessarily and the testing rate was as low as 30.7% – contrary
to guideline recommendations. Similar problems have been observed in Zambia ( Zurovac et al.,
2007); in Kenya (Juma and Zurovac, 2011); and, in Nigeria (Mangham et al., 2011) .

9
Since 2006, no evaluations have been conducted on the implementation of the guidelines in
Nzega district. This has resulted in a gap; that, whether the National Guidelines are observed or
not. The gap, therefore, provided the need for this study to be carried out in Nzega District which
aimed at assessing whether children under five years were managed
1.3 RATIONALE
To achieve effective malaria control in Nzega District, it is absolutely necessary to improve
malaria diagnosis and treatment as per the National Guidelines for malaria case management.
This study will provide scientific evidence on the current practice on malaria case management
in the district in comparison with the guidelines; besides, sharing the resultant information with
authorities in the district, thus more likely, leading to taking corrective measures in order to bring
the practice in conformity with the National Guidelines for malaria diagnosis.ed according to the
recommended National Guidelines for malaria diagnosis and treatment.
1.3.1 HYPOTHESIS
Malaria cases among children under five years of age attending health facilities in Nzega district are managed
according to the National Guidelines.

1.4 STUDY OBJECTIVES

1.4.1 Broad objective
To assess malaria case management practices among children under five years of age attending
health facilities in Nzega District, as per the National Guidelines for malaria case management.
1.4.2 Specific objectives
1) To determine the proportion of children under five years of age with fever attending health
facilities in Nzega District.
2) To determine the proportion of children under five years of age attending health facilities in
Nzega District with parasitological confirmed malaria.
3) To determine the proportion of children under five years of age attending health facilities in
Nzega District given medications.
4) To determine the proportion of children under five years of age receiving anti- malarial drugs
with negative parasitological confirmation in Nzega District.
5) To determine the proportion of health workers who received training on the new guidelines
for malaria case management.
1.5 RESEARCH QUESTIONS
1) What is the proportion of children under five years with fever attending at health facilities in
Nzega District?
2) What is the proportion of children under five years with parasitological confirmed malaria
attending at health facilities in Nzega District?
3) What is the proportion of children under five years who are given medications for
management of malaria at the health facilities in Nzega District?

10
 4) What is the proportion of children under five years receiving anti-malarial drugs with
negative parasitological confirmation in Nzega District?
5) What is the proportion of health care workers who received training on the new guidelines for
malaria case management?
1.6 Variables Dependent variables:
 Malaria Case Management Independent variables:
 Proportion of children with raised body temperature (≤37.50C).
 Proportion of children parasitologically tested with mRDTs or microscopy.
 Proportion of children given medications.
 Proportion of children given antimalarials with negative parasitological test.
Proportion of health care workers trained on the Guidelines for malaria case management

11
2.0 LITERATURE REVIEW
Fever is defined as an elevation of body temperature axillaries ≥ 37.5˚C. Traditionally fever has
served as the entry point for presumptive treatment of malaria in African children (Okiro and
Snow, 2010).
In Tanzania, before the introduction of the guidelines, 30% of the disease burden borne by the
people was from acute febrile illness, predominantly caused by malaria (NMCP, 2007 - 2008).
During this period fever was managed as the marker for the treatment of malaria under the IMCI
guidelines. The IMCI guidelines rely on detection of cases based on simple clinical signs,
without laboratory tests, and offer empirical treatment. The Integrated Management of
Childhood Illness, IMCI, has provided clinical algorithms for managing and diagnosing common
childhood illnesses by minimally trained healthcare providers in the developing world having
inappropriate equipment for laboratory diagnoses (WHO, 1997).
In Tanzania, the IMCI was introduced in 1996 in an attempt to reduce child mortality. Due to
this practice, that is malarial treatment without confirmatory tests, there was a huge outcome of
over-diagnosis and over-treatment in many parts of sub-Saharan Africa including Tanzania
(WHO, 2008; Nsimba et al., 2002; and Font et al., 2001). This practice resulted in drug
resistance of commonly used anti-malarias, Chloroquine and SP.
However, recent changes in the epidemiology of malaria across many places in Africa would
suggest that the predictive accuracy of fever or history of fever as a marker of the disease has
changed prompting calls for change to diagnosis-based treatment strategies (WHO, 2012; and
Okiro and Snow, 2010). This is accompanied by the introductions of new diagnostic test for
malaria, the mRDTs, and anti-malarial drugs, Artemesinin Based Combination Therapy (ACTs).
All these are expensive, and sustainability is questionable, so, there is a need for treating only
individuals who are scientifically proven to have the disease to avoid unnecessary drug use
which will predispose an individual to develop drug resistance and other costs. Studies done in
Tanzania have shown that the use of fever alone as a presumptive prompt for anti-malarial
treatment would result in a huge over-treatment burden (Reyburn et al., 2004; Nsimba et al.,
2002; and Font et al., 2001). This has not only been observed in Tanzania but also in other parts
of sub-Saharan Africa: For example in Nigeria 83.1% of the children with fever who tested
negative were given the ACTs (Oladosu and Oyibo, 2013) and in Uganda, for instance, 75% of
the patients were treated unnecessarily with anti-malarial drugs (Ndyomugyenyi et al., 2007).
Based on this observation, the World Health Organization recommends that malaria treatment
should begin with parasitological diagnosis across all age groups before taking the recommended
ACTs (WHO, 2010; Zarocostas, 2010; and Graz et al., 2011).
Malaria diagnosis is based on clinical criteria, clinical diagnoses, and detection of parasites in the
blood, parasitological diagnoses (Microscope and malaria Rapid Diagnostic Tests). Prompt and
accurate diagnosis of malaria is an essential component of malaria case management as well as a
key for reducing morbidity and mortality (WHO, 2010). Delays in diagnosis and treatment are
proven to be the leading causes of deaths in many countries (Tangpukdee, 2009).

12
In clinical diagnoses, malaria diagnosis and treatment is performed without the benefit of
laboratory support. So, it is based on the signs and symptoms presented by patients: fever, loss of
appetite, vomiting, diarrhoea, anaemia, absence of cough, high temperature (≥ 37.5˚C); and
splenomegaly.
Clinical diagnosis however has some advantages. It is based on observable signs and symptoms,
thus easy to perform; it has got high sensitivity; it is cheap, for, it does not require reagents or
equipment; and, it does not consume time.
On the other hand clinical diagnosis suffers from the following: it has got low specificity; and, it
can lead to misdiagnosis of the presenting illness which can cause an individual to use the drug
inappropriately, wastage of drugs, and over-treatment. Inappropriate drug use or over-treatment
has the effect of predisposing an individual to develop drug resistance which, more probably,
will increase the mortality rate. According to the WHO definition “drug resistance”, is the ability
of the parasite to
survive or multiply despite the administration and absorption of a drug given in doses equal to or
higher than those usually recommended but within the tolerance of the subject. Inappropriate
administration of anti-malarial drugs could contribute to the spread of resistance and lead to
unnecessary costs to be incurred (Mwangi et al., 2005). Clinical practice was understandable in
the past when inexpensive and well-tolerated anti-malarial drugs were still effective.
For decades, as most health facilities in Africa did not perform diagnostic testing, uncomplicated
malaria was typically managed in a syndromic approach in which all patients with febrile illness
were treated with chloroquine (Chandramohan et al., 2002). Clinical diagnosis of malaria is
challenging, because of the non-specific nature of the signs and symptoms, which overlap
considerably with other common as well as potentially life-threatening diseases – common viral
or bacterial infections, and other febrile illnesses (Chandramohan et al., 2002). The overlapping
of malaria symptoms with other tropical diseases impairs diagnostic specificity, which can
promote the indiscriminate use of anti-malarial drugs and compromise the quality of care for
patients with non-malarial fevers in endemic areas (Mwangi et al., 2005). For example in areas
of intense transmission it has been found that reported fever or a history of fever is an unreliable
indicator of clinical malaria (Ndyomugyenyi et al., 2007). In areas of lower malaria transmission
reports showed that there is higher rates of over-diagnosis (Reyburn et al., 2004; and,
Chandramohan et al., 2002).
Reliance on presumptive clinical diagnosis, in the absence of laboratory diagnosis, it has been
concluded, results in diagnostic inaccuracy, and over-diagnosis of malaria (Font et al., 2001; and,
Reyburn et al., 2004). Despite this, for many years, national malaria control programs
recommended treating children under the age of 5 years with fever for malaria, based on febrile
symptoms alone. The reasons for this was that most health facilities did not have working
microscopes; a trained microscope operator; nor necessary equipment – slides and stains – to
perform laboratory tests (WHO, 2010; and, D‟Acremont et al., 2009). As malaria interventions
have been scaled up through massive injections of financial resources and adequately trained

13
medical personnel, in sub- Saharan Africa, in recent decades; rapid diagnostic tests for malaria
have become
available in health facilities, microscopes have been provided, and experts to operate the
microscopes have been trained. As a result, the World Health Organization recommended that all
suspected cases of malaria must be confirmed with a diagnostic test prior to treatment with the
recommended ACTs (WHO, 2010). Therefore at present, clinical diagnosis is no longer reliable
in the diagnosis of malaria.
Malaria is diagnosed microscopically by staining thick and thin blood films on a glass slide, to
visualize malaria parasites. Microscopic detection and identification of Plasmodium species in
Giemsa-stained thick blood films, for screening the presenting malaria parasite and, thin blood
films, for species‟ confirmation, remain the acceptable standard for laboratory diagnosis; and,
Field‟s stain is an option. Giemsa stain is a Romanovsky stain and will stain chromatin materials
red and cytoplasm blue. Materials needed are Giemsa stain, solvent methanol and buffered water
with a PH of 7.2. Field stain consists of the two components of Romanovsky stain in separate
solution. These are called Field stain A and Field stain B. It is used to stain unfixed thick blood
films. The procedure will stain white blood cells, platelets and parasite but will haemolyse the
red blood cells. The main materials required for the procedure are Field stain A solution and
Field stain B solution. And, the method applicable is by dipping the unfixed-dried- thick blood
film in Field stain A for three (3) seconds; then, carefully rinsing the slide in tap water for
another three seconds; followed by dipping the slide in Field stain B for three seconds; and then,
rinsing the slide in water again and then making it stand vertically to dry. Then observe the
specimen under the light microscope, the parasite chromatin will stain red and cytoplasm blue.
The benefits of a microscopic test are many. The microscopes can differentiate the parasite
species and their circulating stages – trophozoites, schizonts, and gametocytes. It is relatively
inexpensive and can provide permanent records of the diagnostic findings. Besides, it is used in
quantification of the malaria parasites. The other advantage is that microscopy of Giemsa-
stained blood film has high sensitivity and specificity when used by a well trained staff; it can
detect as low as 50 parasites per micro-litre of blood under the routine condition (Kyabayinze et
al., 2008; and, Chilton et al., 2006). Recently conventional malaria microscopic diagnosis and
proper training at primary health care facilities has been shown to reduce the prescription of anti-
malarial drugs and, also, it has appeared to improve the appropriate management of non-malarial
fevers (Ngasala et al., 2008).
On the contrary microscopic diagnosis suffers from many shortcomings. It is labour intensive
and time consuming, resulting in longer delays before the results are released; it requires well
trained laboratory technicians; and it needs electricity, so, it is not suitable in remote areas where
electricity is not found – in a word, expensive. Consequently studies done in different settings in
Africa have shown the absence of the diagnostic equipment, microscopes, resulting in clinical
treatment of patients. In Tanzania for example, this was observed in primary health care facilities
whereby 94% of the patients were treated clinically and were given anti-malarial drugs
unnecessarily (Font et al., 2001). Microscopic test remains the agreed standard for diagnosis of
malaria;

14
3.0 METHODOLOGY
3.1 Study design
A descriptive and analytical cross sectional study was conducted at health facilities located in
Nzega district from April to May 2022 to assess malaria case management among children under
the age of five years with respect to the National guidelines for malaria diagnosis and treatment
of Tanzania.
3.2 Study area
The study was conducted in Nzega district, Tabora, Tanzania. Nzega is one of the six districts in
Tabora region; others are Urambo, Igunga, Sikonge, Uyui and Tabora municipal. It has 2
divisions, 16 wards, 57 villages; with 18 dispensaries, 1 health center and 1 district hospital
providing health care services. It has two seasons; the dry season, starting from June to
November; and, the rainy season starting from December to May, with intense rainfalls from
January to April. So, this provides an environment which is important for the breeding sites of
the Anopheles mosquitoes which are the important factors in the disease transmission.
The main activities within the district are farming. Farmers are involved in maize, rice,
groundnuts cultivation and honey production. Rice and Honey are the main crops for the source
of income for the natives within the District. The main language for the natives is Nyamwezi.

3.3 Study population

Children under five years of age who attended health care facilities during day time were
enrolled in the study if they fulfilled the following criteria:
a) Children below the age of 60 months.
b) All sick children who were treated at the outpatient clinics and were exiting the health
facilities.
c) Parents or Care takers consent for their children to participate in the study.

3.4 Sample size estimation.

3.5 Sampling technique and sample selection
Nine dispensaries, one health center and the District hospital were involved in this study. The
total sample size of children from each health facility was recruited proportionally to the average
number of children attending each facility per month. Under fives who fulfilled the inclusion
criteria were consecutively enrolled in each facility until the required sample per facility was
met. Per month, as it was estimated by looking into the health facility register, the dispensary
receives, 100 children, the health centre receives, 200 children and the district hospital receives
600 children. Then from these data, calculations were made to get the total sample size from

15
each type of health facility, therefore 201 under five children were obtained from the randomly
selected nine dispensaries, 45 children were obtained from the health centre and 134 children
were obtained the District hospital
Sample size estimation for the children under five years of age.
The sample size is calculated by using Fischer’s formula:
N = z2PQ
d2
N = Minimum sample size

Z = Constant, Standard normal deviate (1.96 for 95% Confidence level)

P = Population proportion with characteristic of interest (assumed 50% since there

was no previous study at that population)

Q=1–P

d = Acceptable Margin of error

Where, N = the desired sample size

P = Proportion of children under five years of age tested negative and prescribed antimalarials
(32.8%) = 0.328 (Juma and Zurovac, 2011) d= marginal error (5%) = 0.05 N = (1.96 0.05) 2 ×
0.328 (1 – 0.328) = 339
When adding 10% for non responses, drop outs and missing data, the sample size becomes;
(0.1×339) + 339 = 373, rounded to 380
Therefore, the sample size used in this study was 380 children

3.5 Data collection procedure

3.5.1 Pre-testing
Prior to commencing of the study the questionnaires were pre-tested in the two selected
dispensaries to check for clarity, sequencing and logical flow so as to make amendments to the
questionnaires where necessary before starting data collection. All the amendments were done
and the questionnaire was used for the final data collection.
3.5.2 Data collection
Structured questionnaires were used to collect information from parents or care takers of the
recruited children when they are exiting the health facilities and these questionnaires were typed
in Swahili language to easier the understanding. Prior to the interview, informed consent was

16
obtained from parents or care takers and there was no refusal. During exit interviews,
information collected was based on socio- demographic characteristics, history and duration of
fever, parasitological diagnosis done and treatment given. Also body temperature was measured
by the researcher using digital thermometer when the child was recruited in the study.
Information was also collected from patient treatment card (CRF) to verify the information
obtained from the parents or care takers. Information on social demographic characteristics,
working experience, level of education and in service training on the National Guidelines for
malaria diagnosis and treatment were obtained from the health care workers who were available
on the day of the survey. Also questions were asked by the researcher at the health facility on
availability of the guidelines for malaria diagnosis and treatment, diagnostics equipments and
anti-malarial drugs; and, the presence of wall charts on malaria case management. Data were
collected by the principal investigator and the research assistants in all the selected health
facilities.
3.6 Specimen collection and processing.
During the exit interviews, after informed consent was obtained, blood specimens for
examination of malaria parasites were collected from all participating children at the health
facility using sterile blood lancets, absorbent cotton wool, methylated spirit and clean wrapped
slides.
The blood smears were stained by using Giemsa stain as a gold standard. We stained the blood
smears by using Giemsa stain 10%, whereby after each 15 minutes the slides were washed and
kept to dry in air, read for examination of the malaria parasites. We examined the blood slides
under microscope with X100 objectives by using oil emulsion to increase contrast. All
specimens were read at Nzega District Hospital by the principal investigator with the help of the
laboratory technologist of Nzega hospital. Only thick film was made. The second reading was
done at MUHAS under the department of Parasitology. After reading the blood slides for
malaria, any blood slides with malaria parasites of any density was regarded as positive and
those with none were regarded as negative. The aim of sending the blood slides to MUHAS was
for quality control assurance.
3.7 Data analysis
Data was entered, processed and analysed using SPSS soft ware packages. Frequencies were
calculated and X2 test was used for differences between proportions.

3.8 Ethical consideration

The aim of this study and benefits to participants, during the survey, was explained.
Confidentiality of the information collected from participants was protected. Participants were
informed about their voluntary participation and were allowed voluntarily to decide on their own
whether to participate in the study or not. After agreement participants were asked to sign the
consent form as per MUHAS requirements. There was no harmful procedure or treatment which
was used in this study.

17
Ethical clearance was obtained from MUHAS Ethical Review Board. Permission to conduct this
study in Nzega district was obtained from the District Medical Officer (DMO).
3.9 Study limitation
1. A relatively small sample of children who participated in the study may not be a complete
representation of all the children under five who seek health services at the studied health
facilities.
2. Due to the fact that, clinicians were aware that their practices are assessed this bias was likely
to have been promoting a more accurate performance according to the guidelines.

3.9.1 Data collection tool.

Structured questionnaires were used to collect information from parents or care takers of the
recruited children when they are exiting the health facilities and these questionnaires were typed
in Swahili language to easier the understanding. Prior to the interview, informed consent was
obtained from parents or care takers and there was no refusal. During exit interviews,
information collected was based on socio- demographic characteristics, history and duration of
fever, parasitological diagnosis done and treatment given. Also body temperature was measured
by the researcher using digital thermometer when the child was recruited in the study.
Information was also collected from patient treatment card (CRF) to verify the information
obtained from the parents or care takers. Information on social demographic characteristics,
working experience, level of education and in service training on the National Guidelines for
malaria diagnosis and treatment were obtained from the health care workers who were available
on the day of the survey. Also questions were asked by the researcher at the health facility on
availability of the guidelines for malaria diagnosis and treatment, diagnostics equipments and
anti-malarial drugs; and, the presence of wall charts on

18
 4.0 WORK PLAN
ACTIVITIES APRIL MAY
DATE 8-15 16-21 22-30 1-20 21-25 26-30
Proposal writing
Data collection
Data analysis
Submission of research
proposal
Report writing
Presentation and Submission of
final report

19
5.0BUDGET

Items Units Amount Price/ Unit Sub Total Tshs.

Tshs.
Required

Pens Box 1 5,000 5,000

Plain papers(A4) Box 1 17,000 17,000

Printing research Copy and 1 5,000 5,000/=

proposal binded copy

Binding research project Copy 1 10,000 10,000

Transport Motor cycle fee 10 days 20,000 20,000

Meal Hotel 10 days 2000 20,000

Miscellaneous 10,000 10,000

Total money spent 87,000/=

Grand total 115,000/=

malaria case management. Data were collected by the principal investigator and the research
assistants in all the selected health facilities.

20
REFERENCE
Biai, S., Rodrigues, A., Gomes, M., Ribeiro, I., Sodemann, M., Alves, F., Aaby, P., 2007.
Reduced in-hospital mortality after improved management of children under 5 years admitted to
hospital with malaria: randomised trial. BMJ 335, 862–862. Chanda, P., Hamainza, B., Moonga,
H.B., Chalwe, V., Pagnoni, F., 2011. Community case management of malaria using ACT and
RDT in two districts in Zambia: achieving high adherence to test results using community health
workers. Malar J 10, 158. Chandramohan, D., Jaffar, S., Greenwood, B., 2002. Use of clinical
algorithms for diagnosing malaria1. Trop. Med. Int. Health 7, 45–52. Chilton, D., Malik, A.N.J.,
Armstrong, M., Kettelhut, M., Parker-Williams, J., Chiodini, P.L., 2006. Use of rapid diagnostic
tests for diagnosis of malaria in the UK. J. Clin. Pathol. 59, 862–866.
D‟Acremont, Lengeler C, Genton B (2010). Reduction in the proportion of fevers associated
with Plasmodium falciparum parasitaemia in Africa: a systematic review Malar J, 9:240
D‟Acremont, V., Lengeler, C., Mshinda, H., Mtasiwa, D., Tanner, M., Genton, B., 2009. Time
To Move from Presumptive Malaria Treatment to Laboratory-Confirmed Diagnosis and
Treatment in African Children with Fever. PLoS Med 6, e252.
Font, F., Alonso González, M., Nathan, R., Kimario, J., Lwilla, F., Ascaso, C., Tanner, M.,
Menéndez, C., Alonso, P.L., 2001. Diagnostic accuracy and case management of clinical malaria
in the primary health services of a rural area in south-eastern Tanzania. Trop. Med. Int. Health 6,
423–428.
Graz B, Willcox M,Szeless T,Rougemont A (2011), “Test and treat” or presumptive treatment
for malaria in high transmission situations? A reflection on the latest WHO guidelines, Malar J,
10:136

21
APPENDEX
Appendix 1: Informed Consent form, English Version
TABORA POLYTECHNIC COLLEGE (TPC)
INFORMED CONSENT FORM FOR PARENTS OR CARE TAKERS
ID NO.
Consent to participate in research
Greetings! I Bichuro Emanuel, a student from Tabora polytechnic college, doing a study on;
Assessing Malaria Case Management among children under five years attending at health
facilities in Nzega District.
Purpose of this study
The aim of this study is to assess malaria case management practices among children under
under five years attending at health facilities in Nzega district, as per National Guidelines for
Malaria Diagnosis and Treatment.
Confidentiality
All issues pertaining to child participation will be kept confidential and no any unauthorized
person will have access to this information.
Risks
There is no harm for those who will voluntary participate in this study and for those who will be
found with positive blood smear will be treated accordingly.
Benefits

22
Participating in this study allows understanding the quality of malaria case management practices
in your facilities, and which will lead to take the appropriate measures to improve the quality of
care within your district.
Who to Contact
In case you encounter problems you may contact me through this address Bichuro Emanuel
TPC, P.O BOX 1764 TABORA.
Agreement part
I therefore request you to allow your child to participate in this study; participation in this study
will involve asking you some questions on your child’s present illness and also blood slide
sample will be taken for malaria parasite examination and body temperature will also be
measured.
Do you agree? YES: …… NO: …… (Tick appropriately)
I, _______________________________________ have read the consents in this form. My
questions have been answered. I agree to participate in this study with my child.
Parent / Care taker sign: ……………….. Date ……………..
Witness sign (If parent or care taker cannot read)……………… Date……………..
Data collector sign: ………………. Date ……………
56
Appendix 2: Informed Consent form, Swahili Version
CHUO CHA AFYA TABORA POLYTECHNIC
Fomu ya Makubaliano ya Wazazi au Walezi wa mtoto
Namba ya utambulisho
Habari! Mimi naitwa Bichuro Emanuel Gwamiye mwanafunzi wa Chuo Kikuu cha sayansi ya
afya na sayansi shirikishi Muhimbili ninayesomea shahada ya uzamili katika fani ya magonjwa
ya ukanda wa joto.
Dhumuni kuu
Dhumuni la kufanya utafiti huu ni kuangalia jinsi gani ubora katika utendaji juu ya ugonjwa
wa malaria kwa watoto ambao wana umri chini ya miaka mitano unavyofanywa kulingana na
miongozo ya kubaini na kutibu ugonjwa huu wa malaria.
Usiri
Taarifa zote za mshiriki zitatunzwa kwa usiri na kamwe hazitatolewa kwa mtu yeyote
asiyehusika.
Hasara

23
Hapatakuwa na tatizo lolote kwa wale watakaokubali kwa hiari yao wenyewe kushiriki katika
utafiti huu na kwa wale watakaogundulika kuwa wana vimelea vya malaria watapewa dawa.
Faida
Ushiriki wenu katika utafiti huu utasaidia kujua ubora wa huduma zinazotolewa katika vituo
vyenu vya afya na hospitali kulingana na miongozo ya kubainisha na kutibu ugonjwa wa
malaria. Pia utafiti huu utasadia kuboresha huduma za afya kuhusiana na ugonjwa wa malaria
katika wilaya yenu.
Pia kwa wale watoto watakaogundulika na vimelea vya malaria watapata tiba.
Mawasiliano
Kwa yeyote mwenye kutaka kujua zaidi au kapata tatizo kutokana na utafiti huu anaweza
kuwasiliana na mimi kwa barua, akiniandikia kupitia anuani hii Bichuro Emanuel Gwamiye,
TPC, S.L.P 1764 TABORA.
Kipengele cha Makubaliano
Baada ya maelezo hapo juu, nakuomba mzazi au mlezi wa mtoto uweze kumruhusu mtoto
ashiriki katika utafiti huu, pia nitakuuliza maswali kuhusiana na ugonjwa wa sasa wa mtoto
wako, pia nitampima joto lake la mwili na nitamchukua damu kwa ajili ya kwenda katika
chumba cha maabara kwa ajili ya uchunguzi ili kubaini kama ana vimelea vya malaria.
Je Unakubali? Ndiyo: …… Hapana: …… (weka tiki panapostahili)
Mimi ___________________________________________nimesoma maelezo ya fomu hii.
Maswali yangu yote yamejibiwa na ninakubali kwa hiyari yangu mwenyewe kushiriki kwenye
utafiti huu, pamoja na mtoto wangu.
Sahihi ya mzazi au mlezi: ……… Tarehe………
Sahihi ya shuhuda………… Tarehe………
Sahihi ya mtafiti: ………………. Tarehe …………
Appendix 3: Questionnaire, English Version
QUESTIONNAIRE FOR: ASSESSING MALARIA CASE MANAGEMENT AMONG
CHILDREN UNDER FIVE YEARS ATTENDING AT HEALTH FACILITIES IN NZEGA
DISTRICT.
Serial number ____________
Name of the Health facility_________
Name of interviewer_______________
Date of interview _______________
PART A: CHILD‟S PARTICULARS FROM PARENT OR CARETAKER

24
1) Age: year/s ( ) month/s ( ) (fill in the brackets the correct age) 2) Sex: male ( )
female ( ) (Tick accordingly)
3) What are the main complaints of the child? (Tick appropriate) a) Fever b) Vomiting c)
Diarrhoea d) Loss of appetite e) Others (mention) ___________________________________
4) Did your child have fever? (Tick appropriate)
a) Yes
b) No
5) For how long has your child been having fever? (Tick appropriate)
a) Less than 2 days
b) 2 days to 14 days
c) More than 14 days
6) Did you do anything before you came to this health facility concerning your child‟s illness?
(Tick appropriate)
a) Yes
b) No
7) What did you do? (Tick appropriate)
a) I did self medication at home
b) I bought medication from the nearby private chemist
c) I went to private health facility
d) I went to consult tradition healers
8) Did your child take any antimalarial drugs prior to the health facility visit? (Tick appropriate)
a) Yes
b) No
9) What was the type of antimalarial drugs taken? (Tick appropriate)
a) ALu
b) Quinine tablets
c) Quinine injection
d) Others, specify__________________________________
10) Is this your first or your follow up visit to this health facility for your child‟s illness? (Tick
the appropriate response)
a) First visit: Yes ( ) No ( )
b) Follow up visit: Yes ( ) No ( )

25
PART B: INFORMATION OBTAINED FROM PATIENT HOLDING RECORDS OR
PATIENT TREATMENT CARD (CRF)
11) Was the child’s temperature recorded in the health facility? (Tick according to the CRF
records)
a) Yes
b) No
12) Was the child’s weight measured in the health facility? (Tick according to the CRF records)
a) Yes
b) No
13) List the main complaints for the child (list according to the CRF records)
a) b) c) d)
14) Parasitological tests done (delete whichever is not applicable, „positive‟/ „negative‟
according to the CRF records)
a) mRDT ____________________ _______________positive / negative b) Blood slides taken
for malaria parasites __________positive / negative
15) Diagnosis given to the child (delete whichever is not applicable, „Yes‟ / „No‟, according to
the CRF records)
a) Malaria ___________________________Yes / NO
b) Urinary tract infection _______________ Yes / No c) Gastrointestinal infections
____________ Yes / No d) Respiratory tract
infections ___________ Yes / No e) Other diagnoses ________mention
_______________________________
16) Treatment given to the child (Tick only the appropriate TREATMENT according to the CRF
records)
a) Antimalarial drugs b) Antibiotics c) Antipyretic d) Others ___
mention____________________________________________
17) Type of antimalarial given to the child (Tick the appropriate DRUG according to the CRF
records)
a) ALU b) SP c) Quinine tabs or injection d) Other ACTs
PART C: QUESTIONS FOR HEALTH WORKERS (WILL BE DONE BY THE PRINCIPLE
INVESTIGATOR)
1) Age ____________years
2) Sex: male ( ) female ( ) (Tick the appropriate)
3) What is your level of education? (Tick appropriate)

26
 a) Standard seven
b) Form four
c) Form six
d) University level
4) What is your pre-service training? (Tick appropriate)
a) Assistant medical officer b) Clinical officer c) Assistant clinical officer d) Medical attendants
e) Others, specify_________
5) For how long have you been working in this health facility? (Tick appropriate)
a) Below six months b) I year c) 2 years d) 3 years and above
6) Did you get any in-service training on the guidelines for malaria diagnosis and treatment?
(Tick appropriate)
a) Yes b) No
7) If yes, when were you trained?
a) For the last six months
b) For the last one year
c) For the last two years
d) For more than two years ago
8) How many visits by supervisors did you get in the past six months? (Tick appropriate)
a) 0 visit b) 1 visit c) 2 visits
d) 3 or more visits
PART D: INFORMATION FROM THE HEALTH FACILITY ON EQUIPMENT, DRUGS
AND MATERIALS, THIS WILL BE OBTAINED FROM THE HEALTH CARE WORKERS
(TO BE DONE BY THE PRINCIPLE INVESTIGATOR)
8) What are the average numbers of children that are seen per day in the health facility (Fill in
the correct number / figure)
a) Rainy season _____________children b) Dry season ______________children
9) What are the types of antimalarial drugs that are available in the health facility? (Tick
appropriate)
a) ALU b) SP c) Quinine injection d) Quinine tabs e) Others:
mention__________________________
10) What are the types of equipments that are available in the health facility? (Tick appropriate)
a) Weighing scales

27
 b) Working microscopes
c) Malaria rapid diagnostic test kits
d) Others
11) Does the health facility have the National Guidelines for malaria diagnosis and treatment?
(Tick appropriate)
a) Yes. If yes, confirm
b) No 12) What are the types of wall charts do you have in your health facility regarding
malaria case management? (Tick appropriate)
a) ACT dosage charts
b) Quinine dosage charts
c) SP dosage charts
d) There is no wall chart
THANK YOU.

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