LOW RELIABILITY OF HOME-BASED DIAGNOSIS OF MALARIA IN A RURAL COMMUNITY IN WESTERN KENYA Rose Kakai (1), Josephine Nasimiyu (2), 1 Wilson Odero (1) 1 Maseno University, Kenya 2 Bokoli Health Centre, Kenya 2671

Introduction Malaria is one of the most severe public health problems. Severe malaria is associated with delay of presentation at a health facility and late use of anti-malarial drugs [Dunyo et. al. 2000, Sumba et. al. 2008]. WHO recommends that anyone suspected of having malaria should receive dx and Rx with an effective drug within 24 hrs of onset of symptoms [WHO 2005] Definitive dx is based on identifying plasmodia in blood films. However, presumptive treatment without lab ddx has been justified by the scarcity of clinical facilities and the high case fatality rate of malaria in high-prevalence areas. 2672

3 Introduction Consequently, home Rx is acceptable when the patient does not have prompt access to a health-care provider, as is the case for most patients in malaria-endemic areas [WHO 2004,Foster 1995]. Even though febrile illnesses are commonly treated at home, little attention has been paid to the children’s caretakers’ Dx of malaria in the community against lab microscopy.

Objective To determine the proportion of children who tested positive for malaria with routine light microscopy among those whose mothers had made a home-based Dx in a rural community in Western Kenya. 2674

Methods Study setting The study was conducted in Bokoli sub-location, Bokoli location, Webuye division of Bungoma East District, Western Kenya. The area is located near the equator, ≈ 100 km north of Lake Victoria. Malaria is the main cause of patients presenting at the local health centre, with a prevalence of ≈ 30% against clinical diagnosis (Medical records, 2006). 2675

Study design A community-based cross-sectional study. Data collection and analysis From every consecutive household, mothers of children < 5 yrs of age with malaria as diagnosed by their mothers were interviewed (n = 96), to elicit responses regarding age, educ level, malaria Dx and Rx. Duplicate blood smears were collected, stained by field stain A (Methylene blue, Azure) and B (Eosin), and examined using microscopy for presence of malaria parasites Mothers < 18 yrs old and those who did not give consent to participate were excluded. Data was analyzed using descriptive statistics. Association between microscopy and home-based diagnosis was established using chi-square test. 2676

Results 96 children included in study, mean age was 25.6 months. Malaria parasites were detected in only 30/96 (31.2%) of the specimens. All cases were Plasmodium falciparum (Table 1). Elevated temp was the most common criterion for diagnosis of malaria cited by 70/96 (72.9%) mothers. There was no significant association between the mothers’ age or education level and malaria diagnosis (p = 0.58 and 0.46, respectively). 2677

VariableNumber (%) of children’s blood slides: PositiveTotal Age (m) of the children (40) (26.9)26 25 – 361 (11.1)9 37 – 483 (30) (31.2)16 Total30 (31.2%)96 Age (yrs) of mothers (37.5)16 25 – 297 (36.8)19 30 – 345 (29.4)17 35 – 395 (38.5)13 > 406 (27.3)22 Total29 (33.3)87* Mothers’ education level No formal education 3 (10)9 Primary20 (66.7)56 Secondary7 (23.3)31 Total30 (31.2%)96 Table I: Maternal age and education level against blood smear results * = 9 women did not give their ages 2678

9 Figure 1: Children’s age versus mother’s clinical diagnosis against P. facliparum blood smear positive results There was a statistically non-significant trend for a decrease in malaria-pos cases by microscopy as the age of the children increased upto 36m, after which it was reversed upward to stabilize at about 30% (p = 0.51) (Fig. 1).

Received treatment with anti-malaria drug Number (%) of children’s blood slides: PositiveNegativeTotal Yes4 (19.0%)6 (16.7)10 (17.5) No17 (81.0%)30 (83.3)47 (82.5) Total Table II: Malaria diagnosis against treatment of the 96 mothers gave information regarding treatment during the current malaria episode; of these, 10 (17.5%) had received treatment for malaria, but 6 (60%) of these were parasite negative (Table II). This means that only 4/21 (19.0%) with positive smear microscopy received treatment (p=0.05). The most common anti-malaria drugs used were Fansidar (37.8%) and Metakelfin (29.7%).

Conclusions Mothers correctly diagnosed malaria in only about one- third of the cases. Health-care providers’ Dx was similar to that of the mothers. Home-based Dx was independent of maternal age and level of educ. Specific Rx rates were extremely low. Many (80%) cases with smear-pos microscopy had not received any Rx. Malaria is overestimated in our study area if the Dx is based solely on clinical signs, therefore lab confirmation is essential. Policy implications The difficulty of diagnosing malaria accurately at home increases the urgent need for improved diagnostic tools that can be used at the community level in poor populations. Intervention measures are needed to increase the Rx rate to reduce reservoirs and malaria parasite transmission