CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND OF STUDY

Malaria is a life threatening parasitic disease transmitted by female Anopheles mosquitoes.

Malaria is an important cause of death and illness, especially in tropical countries (Takem and

D’Alessandro, 2013; WHO, 2019). Malaria infection in Sub Saharan Africa accounts for over

one million deaths yearly in the region, The most severe forms of and deaths from malaria are

caused by Plasmodium species which rarely producing serious complications, debilitating

relapses, and even death (Ogbu et al., 2015). Major complications of severe malaria can develop

rapidly and progress to death within hours or days (Audu and Abdulsalam, 2015). These include

cerebral malaria, pulmonary edema, acute renal failure, severe anemia, and/or bleeding. Acidosis

and hypoglycemia are the most common metabolic complications. The World Health

Organization (WHO) established criteria for severe malaria that assisted clinical and

epidemiological studies. This project was begun in 1990 and was then revised in 2000 to include

other clinical manifestations and laboratory values that portend a poor prognosis based on

clinical experience in semi-immune patients (Ukibe et al., 2016; WHO, 2019).

Malaria is a protozoan disease caused by Plasmodium parasites, which is one of the leading

causes of mortality and morbidity in many developing countries, with an estimated 3.3 billion

people at risk of malaria worldwide and it is a major health problem in tropical and subtropical

regions (WHO, 2010). It is estimated that the number of cases of malaria rose from 233 million

in 2000 to 244 million in 2005 but decreased to 225 million in 2009 (WHO, 2010). The number

of deaths due to malaria is estimated to have decreased from 985 000 in 2000 to 781 000 in 2009

1
(WHO, 2010). Malaria is the most highly prevalent tropical disease with high morbidity and

mortality, and with high economic and social impact (WHO, 2010).

There have been a considerable number of reports about knowledge, attitudes, and practices

relating to malaria and its control from different parts of Africa. These reports concluded that

mortality and morbidity concerning malaria still exist and that practices for the control of malaria

have been unsatisfactory. However, epidemiological patterns of malaria are widely different

from one place to another. Specific data of a place collected can help in the making of a design

of improved program for strategic malaria control for a particular location (WHO, 2010).

1.2 STATEMENT OF PROBLEM

Malaria has proven to be an endemic infection that poses a threat to all and sundry. Malaria cases

and deaths have been increasing in the country, mainly due to injudicious use of antimalarial

drugs, delayed health seeking, and reliance on the clinical judgment without laboratory

confirmation in most of the peripheral health facilities.

1.3 JUSTIFICATION

There are available effective low-cost strategies for the treatment of malaria, but any attempt to

control a disease such as malaria in an area or locality should first of all be preceded by an

extensive evaluation of the magnitude of the prevailing situation; a complete description of the

health problems of the community comprising an account not only of the prevalence, but also of

the community’s view of its own problems and its use of existing health services. Ascertaining

the factors that influence community and provider acceptance of and adherence to the new

treatment regime was vital to improving the effectiveness of this intervention and reducing the

2
risk of development of drug resistance, and thus reduction in prevalence, towards elimination

and subsequent eradication.

1.4 AIM AND OBJECTIVES

The aim of this study is to compare the diagnostic performance of rapid diagnosis test and

microscopy for the diagnosis of malaria in the above hospitals

The specific objectives are;

 To determine the febrile patients who are positive to RDT and Microscopy

 To analyze samples using two diagnostic methods; the microscopy method and the rapid

diagnostic method

 To compile results and comparatively check the effectiveness of both diagnostic methods

3
 CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 HUMAN MALARIA PARASITE

Malaria is a mosquito-borne infectious disease of humans and other animals caused by

plasmodium spp (WHO, 2016). Malaria causes symptoms such as fever, fatique, vomiting and

headaches. Death could occur in severe cases (Abeku, 2007). The symptoms usually begin one to

two weeks after being bitten. If not properly treated, people may have recurrences of the disease

months later (Abeku, 2007). In those who have recently survived an infection, reinfection usually

causes milder symptoms. This partial resistance disappears over months to years if the person

has no continuing exposure to malaria (Mueller et al., 2007).

The disease is most commonly transmitted by an infected female Anopheles mosquito. Most

deaths are caused by plasmodium falciparum because plasmodium vivax and plasmodium

malariae generally cause a milder form of malaria (Mueller et al., 2007). Malaria is typically

diagnosed by an antigen based rapid kit, in developing nations diagnosis of plasmodium is

usually with the aid of a microscopic examination of blood films (WHO, 2016).

2.2 HISTORY OF MALARIA FEVER

Although the parasite responsible for plasmodium falciparum malaria has been in existence for

50,000-100,000 years, records of malaria fever have been in existence from the beginning of

2700BC in china (Cui et al., 2012).

Historical records suggest malaria has infected humans since the beginning of mankind. The

name “mal aria” (meaning “bad air” in Mediieval Italian) was first used in English in 1974 by H.

4
Walpole when describing the disease. The disease was earlier named augue or mash fever due to

its association with swamps and marshland (Cox, 2002). Malaria has a worldwide distribution. It

was once common across Europe, Asia and North America (Cox, 2002) where it is no longer

endemic, though imported cases do occur. The first effective treatment for malaria was from

plant origin, it was believed that the bark of cinochona tree which contains quinine was curative

against malaria fever infection. These trees are found growing freely on the slopes of the Andes,

mainly in Peru (Greenwood et al., 2005).

Ever since the insight that quinine has antimalarial properties, quinine has become the

predominant malarial medication until the 1920s, when other medications began to be developed.

This era of quinine drugs derivatives was short lived as antimalarial resistant parasites develops

readily. In the 1940s, chloroquine replaces quinine as the treatmwent of both ubncomplicated

and severe malaria until resistance supervened globally in the 1980’s (Rijken et al., 2012; Tanser

et al., 2010).

2.3 EPIDEMIOLOGY OF MALARIA FEVER

Malaria is distributed worldwide throughout the tropics and subtropics. People living in malaria

endemic areas may experience more than one malaria attack even in a single season. The

distribution and determinants of the multiple malaria attacks depend on the local epidemiological

settings. In the hyperendemic areas of Africa, children may suffer repeated Plasmodium

falciparum attacks every 4 to 6 weeks over many years (WHO, 2010; WHO, 2008; Cohen et al.,

2010). Even in low-transmission settings in Africa, it was estimated that on average a person

might have 1–3 episodes of malaria infection in a year (Mendis et al., 2009). A study conducted

in the Thai-Myanmar border region of Southeast Asia, where both plasmodium falciparum and

5
Plasmodium vivax are symptomatic, found that the cumulative proportions of patients having

recurrent plasmodium falciparum and plasmodium vivax infections within 63 days after

treatment of acute plasmodium falciparum malaria were 21.5% and 31.5%, respectively (Hiwat

et al., 2010).

The number of estimated direct deaths due to malaria worldwide has decreased from 985,000 in

2000 to 781,000 in 2009 (WHO, 2010). Although malaria remains a major health burden in

tropical and subtropical countries; with the majority of cases in sub-Saharan Africa, several

regions show an impressive decline of malaria cases and a lower number of malaria-associated

deaths. A renewed global interest in malaria eradication and increased international funding has

boosted malaria control efforts all over the world. The elimination of malaria from low-

transmission areas seems feasible. Throughout history, Suriname is one of the countries that have

effectively decreased the incidence of malaria cases within its borders. Impressively, it has

reduced the number of registered malaria cases from 14,403 in 2003 to 1371 in 2009, from which

689 were confirmed by microscopy and 682 by rapid diagnostic testing (RDT) (WHO, 2008).

Certain anti-malarial measures are known to be effective in malaria transmission areas

throughout the world, but in order to move towards a stable situation of control and after that to

the elimination (Cohen et al., 2010; Mendis et al., 2009) of Malaria, country- and region-specific

tools need to be implemented.

Malaria was once transmitted in many parts of the world, for example, as far north as North

Dakota in the United States (Beadle et al., 2000). Due both to environmental changes and to

eradication campaigns conducted in the years after World War II, endemic malaria transmission

has been eliminated from many areas, including the United States and Europe. The disease is still

widely transmitted in the tropics and subtropics (Bruce, 1999). In these areas malaria

6
transmission may be endemic, occurring predictably every year, or it may be epidemic, occurring

sporadically when conditions are correct. Endemic transmission of malaria may be year-round or

seasonal. In some areas of Africa, 90 to 100 percent of children less than 5 years old have

malaria parasites circulating in their blood all the time. Because naturally acquired immunity

develops with increasing exposure, in endemic areas malaria disease is primarily found in

children. In epidemic areas, on the other hand, naturally acquired immunity falls off between

epidemics, and malaria therefore affects all age groups during epidemics.

In the late 1950s and early 1960s, it was thought that malaria could be eradicated through the

widespread use of insecticides such as DDT and by treatment of cases with chloroquine

(Kozarsky and Lobel, 2009; Tanner and Teuscher, 2005).

Eradication is no longer thought possible, however, because of the development of drug

resistance by both the mosquito and the parasite, and because of deteriorating social and

economic conditions in many malaria-endemic countries (Hoffman, 2002). These changes have

resulted in a dramatic increase in the incidence of malaria in many parts of the world, and an

increase in malaria-related mortality in some of these areas (Mendis and Carter, 2015).

2.4 SIGN AND SYMPTOMS OF MALARIA FEVER

The most characteristic symptom of malaria is fever. Other common symptoms include chills,

headache, myalgias, nausea, and vomiting. Diarrhea, abdominal pain, and cough are occasionally

seen. As the disease progresses, some patients may develop the classic malaria paroxysm with

bouts of illness alternating with symptom-free periods (Beadle et al., 2000). The malaria

paroxysm comprises three successive stages. The first is a 15-to-60 minute cold stage

characterized by shivering and a feeling of cold. Next comes the 2-to-6 hour hot stage, in which

7
there is fever, sometimes reaching 41°C, flushed, dry skin, and often headache, nausea, and

vomiting. Finally, there is the 2-to-4 hour sweating stage during which the fever drops rapidly

and the patient sweats. In all types of malaria, the periodic febrile response is caused by rupture

of mature schizonts. In plasmodium vivax and plasmodium ovale malaria, a brood of schizonts

matures every 48hr, so the periodicity of fever is tertian (“tertian malaria”), whereas in

plasmodium malariae disease, fever occurs every 72 hours (“quartan malaria”). The fever in

falciparum malaria may occur every 48hr, but is usually irregular, showing no distinct

periodicity. These classic fever patterns are usually not seen early in the course of malaria, and

therefore the absence of periodic, synchronized fevers does not rule out a diagnosis of malaria

(Hoffman, 2002).

2.5 COMPLICATIONS OF MALARIA FEVER

Patients with complicated malaria occasionally show evidence of massive intravascular

hemolysis with hemoglobinemia and hemoglobinuria. If the diagnosis of malaria is missed or

delayed, especially with plasmodium falciparum infection, potentially fatal complicated malaria

may develop (Bruce, 1999). The most frequent and serious complications of malaria are cerebral

malaria and severe anemia. Cerebral malaria is defined as any abnormality of mental status in a

person with malaria and has a case fatality rate of 15 to 50 percent. Other complications include:

hyperparasitemia (more than 3 to 5 percent of the erythrocytes parasitized); severe

hypoglycemia; lactic acidosis; prolonged hyperthermia; shock; pulmonary, cardiac, hepatic, or

renal dysfunction; seizures; spontaneous bleeding; or high-output diarrhea or vomiting. These

manifestations are associated with poor prognosis (Bruce, 1999). Persons at increased risk of

severe disease from malaria include older persons, children, pregnant women, nonimmune

persons and those with underlying chronic illness. Other complications of malaria infection

8
include gram-negative sepsis, aspiration pneumonia and splenic rupture, spontaneous bleeding,

coagulopathy and shock (Hawman et al., 2013).

2.6 PATHOGENESIS OF MALARIA FEVER

Clinical illness is caused by the erythrocytic stage of the parasite. No disease is associated with

sporozoites, the developing liver stage of the parasite, the merozoites released from the liver, or

gametocytes (Rijken et al., 2012).

The first symptoms and signs of malaria are associated with the rupture of erythrocytes when

erythrocytic-stage schizonts mature (Rijken et al., 2012). This release of parasite material

presumably triggers a host immune response. The cytokines, reactive oxygen intermediates, and

other cellular products released during the immune response play a prominent role in

pathogenesis, and are probably responsible for the fever, chills, sweats, weakness, and other

systemic symptoms associated with malaria. In the case of falciparum malaria (the form that

causes most deaths), infected erythrocytes adhere to the endothelium of capillaries and

postcapillary venules, leading to obstruction of the microcirculation and local tissue anoxia. In

the brain this causes cerebral malaria in the kidneys it may cause acute tubular necrosis and renal

failure; and in the intestines it can cause ischemia and ulceration, leading to gastrointestinal

bleeding and to bacteremia secondary to the entry of intestinal bacteria into the systemic

circulation. The severity of malaria-associated anemia tends to be related to the degree of

parasitemia. The pathogenesis of this anemia appears to be multifactorial. Hemolysis or

phagocytosis of parasitized erythrocytes and ineffective erythropoiesis are the most important

factors, and phagocytosis of uninfected erythrocytes and an autoimmune hemolytic anemia have

also been implicated. Massive intravascular hemolysis leading to hemoglobinuria and renal

9
failure is referred to as blackwater fever. It was described more frequently in the past than

currently. Hemolysis may also occur after the use of certain antimalarials (especially

primaquine) in patients with glucose 6-phosphate dehydrogenase deficiency (Rijken et al., 2012;

Beadle et al., 2000). Acquired immunity can also protect against malaria infection and the

development of malaria disease. In malarious areas, both the prevalence and severity of malaria

infections decrease with age. However, in contrast to many viral infections, multiple infections

with malaria do not confer longlasting, sterile protective immunity. Virtually all adults in malaria

endemic areas suffer repeated malaria infections. Individuals who are repeatedly exposed to

malaria develop antibodies against many sporozoite, liver-stage, blood-stage, and sexual-stage

malaria antigens. It is thought that antibodies acting against sporozoites, liver-stage and blood-

stage organisms are responsible for the decreased susceptibility to malaria infection and disease

seen in adults in malaria endemic areas and those antibodies against the sexual stages of

plasmodia may reduce malaria transmission. Additional work also suggests that the naturally

acquired immunity includes the release of cytokines that act against all stages of the parasite, and

also a cytotoxic T cell response directed at liver stages of the parasite (Miller et al., 2006)

Acquired antibody-mediated immunity is apparently transferred from mother to fetus across the

placenta. This passively transferred immunity is lost within 6 to 9 months, as is the immunity in

adults if they leave a malaria endemic area and are no longer exposed to plasmodia. Pregnant

women, particularly primigravidas, are more susceptible to malaria infections and serious disease

(Miller et al., 2006).

10
2.7 LABORATORY DIAGNOSIS OF MALARIA FEVER

Definitive diagnosis of malaria generally requires rapid diagnostic testing (RDT) (WHO, 2008)

or direct observation (Microscopy) of malaria parasites in Giemsa-stained thick and thin blood

smears. Thin blood smears, in which parasites are seen within erythrocytes, are used to

determine the species of the infecting parasite. The presence of diagnostic forms can vary

markedly with the stage of the life cycle, especially early in disease. In plasmodium falciparum

malaria, most organisms are not present in the peripheral blood because they are sequestered in

the micro vascular tissue of internal organs. If malaria is suspected, blood smears should be

examined every 6 to 12hr for at least 2 days.

2.7.1 Microscopic Tests

For nearly a hundred years, the direct microscopic visualization of the parasite on the thick

and/or thin blood smears has been the accepted method for the diagnosis of malaria in most

settings, from the clinical laboratory to the field surveys. Light microscopy of thick and thin

stained blood smears remains the standard method for diagnosing malaria. It involves collection

of a blood sample, its staining with Giemsa or alternative stains and examination of the Red

Blood Cells for intracellular malarial parasites. Thick smears are 20–40 times more sensitive

than thin smears for screening of Plasmodium parasites, with a detection limit of 10–50

trophozoites/µl. A Thin smear allow one to identify malaria species (including the diagnosis of

mixed infections), quantify parasitaemia, and assess for the presence of schizonts, gametocytes,

and malarial pigment in neutrophils and monocytes. The diagnostic accuracy relies on the quality

of the blood smear and experience of laboratory personnel (Miller et al., 2006).

11
Before reporting a negative result, at least 200 oil immersion visual fields at a magnification of

100× should be examined on both thick and thin smears, which have a sensitivity of 90%. The

level of parasitaemia may be expressed either as a percentage of parasitized erythrocytes or as

the number of parasites per micro litre of blood. In non-falciparum malaria, parasitaemia rarely

exceeds 2%, whereas it can be considerably higher (>50%) in falciparum malaria. In non-

immune individuals, hyper parasitaemia (>5% parasitaemia or >250 000 parasites/µl) is

generally associated with severe disease (Miller et al., 2006).

2.7.2 Rapid Diagnostic Tests (RDTs)

Although the peripheral blood smear examination that provides the most comprehensive

information on a single test format has been the "gold standard" for the diagnosis of malaria, the

immunochromatographic tests for the detection of malaria antigens, developed in the past

decade, have opened a new and exciting avenue in malaria diagnosis. Immunochromatographic

tests are based on the capture of the parasite antigens from the peripheral blood using either

monoclonal or polyclonal antibodies against the parasite antigen targets. Currently,

immunochromatographic tests can target the histidine-rich protein 2 of P. falciparum (PfHRP2),

a pan-malarial Plasmodium aldolase, and the parasite specific lactate dehydrogenase (pLDH)

(Moody, 2002). These RDTs do not require a laboratory, electricity, or any special equipment.

PfHRP2 is a water soluble protein that is produced by the asexual stages and gametocytes of P.

falciparum, expressed on the red cell membrane surface, and shown to remain in the blood for at

least 28 days after the initiation of antimalarial therapy. Plasmodium aldolase is an enzyme of the

parasite glycolytic pathway expressed by the blood stages of P. falciparum as well as the non-

falciparum malaria parasites.

12
The PfHRP2 test strips have two lines, one for the control and the other for the PfHRP2 antigen.

The PfHRP2/PMA test strips and the pLDH test strips have three lines, one for control, and the

other two for P. falciparum (PfHRP2 or pLDH specific for P. falciparum) and non-falciparum

antigens (PMA or pan specific pLDH), respectively. Change of colour on the control line is

necessary to validate the test and its non-appearance, with or without colour changes on the test

lines, invalidates the test.

With color change only on the control line and without color change on the other lines, the test is

interpreted as negative. With the PfHRP2 test, color change on both the lines is interpreted as a

positive test for P. falciparum malaria. With the PfHRP2/PMA [the immunochromatographic

test (ICT Malaria P. f. /P.v.test)] and the pLDH tests, color change on the control line and the

pan specific line indicates non-fa1ciparum infection and color change on all the 3 lines indicates

the presence of P. falciparum infection, either as mono-infection or as a mixed infection with

non-falciparum species. Also, if the PfHRP2 line is visible when the PMA line is not, the test is

interpreted as positive for P. falciparum infection. Mixed infections of P. falciparum with the

non-falciparum species cannot be differentiated from pure P. falciparum infections. However,

with regard to the pLDH test, it is claimed that in the presence of P. vivax infection, the genus

specific line is much darker and more intense than the species specific line due to the presence of

all the stages of the parasite in the blood.

Both of these tests are fast, easy to perform and are highly sensitive and specific. Although rapid

diagnostic assays detects malaria antibodies and antigens. These techniques are used primarily in

epidemiologic studies and immunization trials and rarely in the diagnosis of individual patients.

13
2.8 PREVENTION OF MALARIA FEVER

Malaria may be prevented by chemoprophylaxis and personal protective measures against the

mosquito vector and by community-wide measures to control the vector. Exposure to night-

feeding Anopheles mosquitoes is reduced by using protective clothing, insect repellents,

insecticides, insecticide-impregnated bed nets, etc. Mosquitoes may be reduced by destroying

breeding places and by application of insecticides. Vaccines are being developed (Lengeler,

2004).

To prevent malaria it is important to take steps to avoid being bitten by mosquitoes, as they are

the primary way in which the malaria parasite is transmitted. Some ways to prevent mosquito

bites include using insect repellents, wearing long sleeves and pants, using mosquito nets and

avoiding areas where mosquitoes are present. Additionally, it is important to take anti-malarial

medication if you are traveling to an area where malaria is prevalent. Taking these simple steps

can greatly reduce your risk of contracting malaria (Lengeler, 2004).

2.9 CONTROL AND TREATMENT OF MALARIA

The control of malaria can be achieved through a combination of measures aimed at reducing the

spread of the disease. These measures include vector control, such as the use of insecticides and

mosquito nets and case management which involves diagnosing and treating patients who have

contracted malaria. In addition, environmental management such as reducing breeding sites for

mosquitoes and the use of insecticide-treated bed nets can also help to control malaria. By

implementing these measures, it is possible to significantly reduce the burden of malaria in

affected areas (WHO, 2019).

14
The treatment of malaria involves using anti-malarial drugs to kill the parasite that causes the

disease. There are a number of different drugs that can be used to treat malaria and the specific

drug or combination of drugs that is used will depend on the severity of the infection and the area

where the infection was acquired. In some cases, a combination of drugs is used to prevent the

development of resistance to the drugs. It is important to complete the full course of treatment

even if the symptoms resolve to ensure that the infection is fully cleared (WHO, 2019).

The widespread resistance of plasmodium falciparum to chloroquine complicates treatment of

falciparum malaria. Alternative drugs such as mefloquine, pyrimethamine/sulfadoxine

(FansidarR), quinine, quinidine, halofantrine and artemisinin derivatives (qinghaosu) are used.

Chloroquine remains highly effective against plasmodium malariae and plasmodium ovale

malaria, and against plasmodium vivax everywhere except Papua New Guinea and parts of

Indonesia, where significant resistance has developed. Disease caused by plasmodium vivax and

plasmodium ovale requires primaquine to eradicate latent liver forms of the parasite (WHO,

2019).

15
 CHAPTER THREE

3.0 METHODOLOGY

3.1 STUDY AREA

This study was conducted in Anyigba metropolis, Kogi State which is located at longitude

7.49oN and latitude 7.17oE in Kogi State. It has a total land area of about 29,833 sq.km, North

Central Geo-political Zone of Nigeria. The vegetation is Guinea savannah with mean annual

rainfall of 250 cm. Malaria transmission is throughout the year.

Fig 3.1: Map of Kogi State showing Anyigba

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3.2 STUDY POPULATION

The study population comprises of 100 febrile patients attending both Grimard Catholic Hospital

and Prince Abubakar Audu University Teaching Hospital.

3.3 ETHICAL CLEARANCE

The ethical clearance was obtained from the hospital management board

Questionnaires and consent forms were administered to the febrile patients who consented after

seeking their consent to determine the relevant variables.

3.4 BLOOD SAMPLE COLLECTION

A total of 100 samples were collected (among febrile patients) and questionnaire was

administered with relevant variables. The blood specimen was collected by venous puncture

using standard method from the consented patients and transferred into collection tubes

containing Ethylene-diamine-tetra acetic acid (EDTA) to prevent coagulation. Step by step

procedures of the sample collection are outlined below:

 A tourniquet was tied round the patient’s arm to reveal the prominent vein

 The site for sample collection was disinfected using a cotton swab soaked with

methylated spirit

 Blood sample was carefully collected using needle and syringe (venial puncture)

 Collected blood sample was dispensed into an ethylene diamine tetracetate bottle

(EDTA)

 Sample was then transported to the microbiology laboratory of Prince Abubakar Audu

University, Anyigba in an ice pack for analysis

17
3.5 LABORATORY PROCEDURES

Rapid Diagnostic Test Analysis

A rapid diagnostic test kit was used to test for malaria in the samples collected.

Procedures;

• The malaria test pouch was opened and the test strip was placed gently on a sterile work

bench

• With the aid of a Pasteur pipette, a drop of the blood was added in the sample area of the

test strip followed by 2 drops of buffer solution

• The results was read after about 15 minutes

• Results; the results was read with the aid of a test line and a control line appearing on the

surface of the test strip to determine positive and negative samples for malaria. If positive

there will be two lines on the control and test region but if negative there will only be a

line on the control region. Invalid result is denoted by a line on the test region alone or

the absence of no line at all.

Direct Microscopy

Thin and thick smear were made on clean glass slides from the patient’s whole blood samples

and stained with the Giemsa’s stain on the same slide. It was observed under the oil immersion

objective at x100 magnification of the light microscope. The presence of the ring form of the

Plasmodium spp. with reddish or pink coloration signifies a positive result.

18
3.6 STATISTICAL ANALYSIS

The data generated on prevalence was analyzed using statistical programme for service solution

(SPSS) 17.0 Window versions. The statistical significance of variables was estimated using Chi-

square test. Pearson correlation analysis was used to establish possible correlation of prevalence

with parity, age, trimester. P-values of equal to or less than 0.05 was taken as measures of

significance. Data on Knowledge and Attitude was analyzed also using SPSS version 17.0 for

Window. Cross tabulations of important variables were done and the statistical significance of

variables was estimated using Chi-square test.

19
 CHAPTER FOUR

4.0 RESULTS

Figure 4.0 shows the relationship between the two diagnostic tests. It was observed from the

result presented in figure 4.0 that some test appeared to be negative using rapid diagnostic test

(RDT) but under microscopy showed the presence of malaria parasite (Plasmodium falciparum).

While some other results also appeared positive using RDT but no parasite was observed under

the microscope.

Only Microscopy
RDT and n=32
Microscopy
n=43

43% 32%

Figure 4.0: Relationship between rapid diagnostic test (RDT) and Microscopy

20
Table 4.1 shows the gender distribution of respondents screened in the study and their positivity

levels to the both diagnostic techniques used in the study

21
4.1 GENDER DRISTIBUTION OF RESPONDENTS AND THEIR POSITIVITY LEVELS

GENDER NO. NO. +VE TO RDT NO. +VE TO X2 P-value

EXAMINED AND ONLY
MICROSCOPY MICROSCOPY
(%) (%)
Male 42 20 (47.62%) 16 (38.10%) 23.8 0.60

Female 58 23 (39.67%) 16 (27.59%)

Total 100 43 (43.00%) 32 (32.00%)

KEYS: RDT = Rapid diagnostic test

X2 = Chi square value

P-value = Probability value at 95% confidence interval

NO. = Number

+VE = Positive

22
Table 4.2 shows the results of the respondents from the two diagnostic methods used in the study

with respect to age of the respondents. The age group 18 – 23 years showed higher positivity for

both rapid diagnostic test method and microscopy 17 (39.53%) and also for only microscopy

method 12 (27.91%) while the lowest result for rapid diagnostic and microscopy was observed

among the age group 48 – 53 years with 0 (0%) result and lowest result for only microscopy was

observed among age group 54 – 59 years with 1 (25.00%) result.

23
4.2 POSITIVITY RESULTS FROM RDT AND MICROSCOPY TESTS IN RELATION TO AGE
GROUPS

AGE NO. EXAMINED NO. +VE TO NO. +VE TO X2 P-value

RDT AND ONLY
MICROSCOPY MICROSCOPY
(%) (%)
18 – 23 43 17 (39.53) 12 (27.91) 23.8 0.60
24 – 29 22 12 (54.55) 7 (31.82)
30 – 35 10 4 (40.00) 3 (30.00)
36 – 41 08 4 (50.00) 1 (12.50)
42 – 47 04 2 (50.00) 2 (50.00)
48 – 53 07 0 (0) 5 (71.43)
54 – 59 04 2 (50.00) 1 (25.00)
60 – 65 02 2 (100) 1 (50.00)
Total 100 43 (43.00) 32 (32.00)

KEYS: RDT = Rapid diagnostic test

X2 = Chi square value

P-value = Probability value at 95% confidence interval

NO. = Number

+VE = Positive

24
Table 4.3 shows the prevalence of malaria with respect to predisposing factors. In relation to

number of persons staying in a room, those who stay multiple in a room showed a highest

prevalence of 17 (21.25%) and a low prevalence in those who stay singly in a room 2 (10.00%)

with significant difference of p-value 0.02 (p<0.05). With respect their use of mosquito nets,

those who do not use mosquito nets showed a higher prevalence rate 21 (33.33%) and a low

prevalence among those who use mosquito nets 5 (13.51%), there is a significant difference

between these variables as they have a statistically significant p-value of 0.04 (p<0.05). In

relation to those who sit outside at night, those who sit out at night showed a higher prevalence

of 16 (37.21%) while those who do not sit outside at night showed a lower prevalence of 12

(21.05%) with no significant difference between them as p-value is not less than 0.05 (p>0.05,

p=0.37). With respect to those who have bushes around their houses, highest prevalence was

observed among those who have bushes around their houses 13 (36.11%) and low prevalence

was observed among those who do not have bushes around their houses 9 (14.10%), there was a

statistical significance between the variables as p-value is 0.035 (p<0.05). In relation to having

stagnant water around the house, those who did have stagnant water around their houses showed

highest prevalence of the infection 11 (20.37%) and those who did not have stagnant water

around their houses showed lowest prevalence 9 (19.57%), there was no significant difference

between these variables (p-value=0.47, p>0.05). With respect to how frequent they treat malaria

in a year, those who treat malaria once a year had the highest prevalence of 5 (13.16%) followed

by those who treat malaria twice a year 4 (9.76%) and the lowest prevalence among those who

treat malaria more than twice a year 3 (14.29%), there was no significant difference between the

variables as p-value=0.73 (p>0.05)

25
4.3 PREVALENCE OF MALARIA INFECTION WITH RESPECT TO PREDISPOSING
RISK FACTORS

RISK FACTOR NO. EXAMINED NO. POSITIVE X2 P-value

(%)
Number Of Persons In A Room
Single 20 2 (10.00%) 19.1 0.02
Multiple 80 17 (21.25%)
Total 100 19 (19.00%)

Use of Mosquito Nets

Yes 37 5 (13.51%) 23.4 0.04
No 63 24 (38.09%)
Total 100 29 (29.00%)

Sit Outside At Night

Yes 57 12 (21.05%) 19.7 0.37
No 43 16 (37.21%)
Total 100 28 (28.00%)

Bushes Around The Houses

Yes 36 13 (36.11%) 39.4 0.035
No 64 9 (14.06%)
Total 100 22 (22.00%)

Stagnant Water Around The Houses

Yes 54 11 (20.37%) 9.52 0.42
No 46 9 (19.57%)
Total 100 20 (20.00%)

Frequency of Treating Malaria in a Year

Once 38 5 (13.16%) 13.2 0.73
Twice 41 4 (9.76%)
More 21 3 (14.29%)
Total 100 12 (12.00%)

KEYS: RDT = Rapid diagnostic test

X2 = Chi square value

P-value = Probability value at 95% confidence interval

NO. = Number

+VE = Positive

26
 CHAPTER FIVE

5.0 DISCUSSIONS, CONCLUSION AND RECOMMENDATIONS

5.1 DISCUSSIONS

A total of 100 samples were screened for this comparative study of two different

diagnostic methods of malaria, a total of 75 (75.00%) showed positive results for both rapid

diagnostic test and microscopy methods of diagnosis (Table 4.1) This result is relatively high

compared to the work of (Mfuh et al., 2019) who reported a total positivity level of 65%.

In relation to the gender of the respondents’ (Table 4.1) positive results were higher in

rapid diagnosis and microscopic methods for both male and female but was higher in the female

gender than in the male which could be attributed to activeness and energetic nature of the male

gender compared to the female gender. This report observation disagrees with that of

Muhammad et al., (2020) who reported higher prevalence in males than in females.

This research observation showed higher positive results of malaria for rapid diagnostic

test among age groups 18 – 23 years with 17 (39.53%) for rapid diagnostic test and microscopy,

12 (27.91%) for only microscopy and lesser positive results among age group 48 – 54 with 0

(0%) for rapid diagnostic test and microscopy, age group 54 – 59 years with 1 (25.00%) for only

microscopic method of diagnosis, this research finding could be attributed to the activeness and

exposure of the young ones in comparison to the older ones as the level of positivity was

observed to decrease as the age group increased. This research observation agrees with the report

of Muhammad et al. (2020) who reported similar decrement in positivity level with increment in

age (Table 4.2) (Mac et al., 2019)

27
 It should be noted that female individuals were found to be more sensitive to rapid

diagnostic tests as well as microscopy 23 (39.66%) than the male counterpart 20 (47.62%), both

gender were sensitive to only microscopic diagnosis 16 (38.10%) for male and 16 (27.59%) for

female as revealed in this study (Table 4.1) The variation in the use of rapid diagnostic test

diagnosis could be attributed to the genetic make-up and physiology of the male as a contributing

factor since the working principle of RDT is based on antigen – antibody compatibility. This is

similar and agrees with the findings and reports of Madkhali et al. (2022) who also reported

higher sensitivity in the female gender than in the male gender for rapid diagnostic test

(Madkhali et al., 2022)

This study (Table 4.3) also revealed the various risk factors that predispose respondents

to the infection and it has shown higher prevalence among those who stay multiple in a room 17

(21.25%), those who do not use mosquito nets 21 (33.33%), those who sit out at night 16

(37.21%), those who have bushes around their houses 13 (36.11%), those who have stagnant

water around their houses 11 (20.37%) and those who treat malaria only once in a year 5

(13.16%) while their varying counter variables had low rates of malaria prevalence. They are all

predisposing risk factors that lead to exposure and eventually manifestation of the malarial

infection. These finding agrees to the reports of Ramdzan et al. (2020) who reported similar

predisposing risk factors of malarial infection (Ramdzan et al., 2020).

Finally, it is worthy of note that some of the variables used in analyzing results were of

statistical significance with p-value less than 0.05 at 95% confidence interval (p<0.05) while

some were not of statistical significance with p-value greater than 0.05 at 95% confidence

interval (p>0.05)

28
5.2 CONCLUSION

Comparative analysis is always helpful in determining the effectiveness and efficiency of

diagnostic methods that exists for any infection. This study has been able to reveal the efficiency

level of two diagnostic methods that exists for the diagnosis of malarial infections, it has been

proven efficient to use both diagnostic methods as earlier established, rapid diagnosis still

remains the fastest and easiest means of diagnosing malaria but in most cases it is always better

to check with microscopy for confirmation purposes.

29
5.3 RECOMMENDATIONS

It is recommendable to use both rapid diagnostic technique of diagnosis as well as

microscopy technique as both are efficient and effective in the diagnosis of malarial infection. It

is also recommendable for health care facilities to imbibe the habit of always checking results

from rapid diagnostic tests for confirmation purposes when the case seems to be severe and at the

chronic stage using microscopic test methods.

30
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