1. Background Objective Methods Results Discussion Assessing the Risk of Self- diagnosed Malaria in Urban Informal Settlements Yazoumé Yé Elizabeth Kimani John Kebaso Frederick Mugisha Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

2. Background Objective Methods Results Discussion Malaria Endemicity in Kenya In Kenya, malaria is the leading cause of outpatient attendance in 6/8 provinces Level of malaria transmission varies across the country Different malaria epidemiological zones namely:  endemic zone,  epidemic prone zone  low risk zone. Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

3. Background Objective Methods Results Discussion Malaria in Nairobi Nairobi, is classified as a low risk area High altitude (1700m) => cold temperatures limit transmission Urban habitat is less suitable for An. gambiae s.s. and An. Funestus Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

4. Background Objective Methods Results Discussion History of Malaria Cases in Nairobi 1926: Presence in Nairobi of An. gambiae and An. Funestus 1929: A school survey showed 2.5% parasites prevalence 0 200 400 600 800 1000 1200 1930s1940s1950s1960s Reported cases of malaria Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

5. Background Objective Methods Results Discussion Low Prevalence of Malaria in Nairobi Pf prevalence at sites across the city in 1982 (Rapuoda & Achola, 1984) 0%2%4%6%8%10%12%14% Mwimuto Embakasi Kangemi Dandora/Umoja Kaloleni Makadara South B Dagoretti Makongeni Pf prevalence Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

6. Background Objective Methods Results Discussion Malaria Diagnosis in Nairobi Malaria is a common diagnosis among out-patients in the city Overuse of anti-malaria drug With introduction of ACT accurate diagnosis is needed Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

7. Background Objective Methods Results Discussion Questions What is the level of self-diagnosed malaria in the community? Does the population from informal settlements perceive malaria as one of their key morbidities? Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

8. To explore the risk of perceived malaria and associated factors in two Nairobi informal settlements Background Objective Methods Results Discussion Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

9. Background Objective Methods Results Discussion Study Population Household survey May-August 2004 7288 individuals from DSS database Population of interest = 1394 individuals (reported at least one illness ) Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

10. Background Objectives Methods Results Discussion Morbidity Survey Self report of maximum of three illnesses and associated symptoms Recall period: Past 15 days Proxy respondents for participants <14 years Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

11. Background Objectives Methods Results Discussion Statistical Analysis Outcome: Reported malaria (Y/N) Explanatory variables: Slum of residence, sex, age, ethnicity, symptom score Multivariate Logistic regression mode Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

12. Background Objective Methods Results Discussion Computation of Symptom Scores Tiredness Loss of appetite Abdominal pain Diarrhoea Fever Convulsions Headache Vomiting Joint pain Selected symptoms malaria: Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

13. Background Objectives Methods Results Discussion Computation of Symptom Scores, cont Score= Fever + other symptoms Score=0, none of these symptoms Score=1, only fever was reported Score=2, fever+ 1 symptom Etc Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

14. Background Objective Methods Results Discussion Factorsn% Ethnicity Kikuyu36726.3 Kamba31122.3 Luha19914.3 Luo30521.9 Other21215.2 Symptoms Score 041329.6 Score 113910.0 Score 229120.9 Score 329020.8 Score 416812.1 Score 5+936.7 Factorsn% N1394100 Slums Korogocho81858.7 Viwandani57641.3 Sex Female65446.9 Male73953.0 Age group (years) <534324.6 5-1423516.9 15-2421415.4 25-3936726.3 >4023516.9 Study Population Characteristics Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

15. Background Objective Methods Results Discussion Top Five Illnesses 416 392 320 165 3635 30 0 50 100 150 200 250 300 350 400 450 Number of Cases Other (160 illnesses) MalariaCommon coldDon't knowTyphoidPneumoniaAsthma Illnesses Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

16. Background Objective Methods Results Discussion Factorscases% Ethnicity, x 2, p<0.001 Kikuyu8322.6 Kamba10132.5 Luha6331.7 Luo10835.4 Other3717.5 Symptoms, x 2, p<0.001 Score 0245.8 Score 11510.8 Score 210134.7 Score 312543.1 Score 47645.2 Score 5+5154.8 Factorscases% N39228.1 Slums, x 2, p=0.008 Korogocho20834.1 Viwandani18446.9 Sex, x 2, p=0.250 Female17426.6 Male21829.5 Age group (yrs), x 2, p<0.001 <58123.6 5-145021.3 15-246028.0 25-3913637.1 >406527.7 Distribution of Self-diagnosed Malaria Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

17. Background Objectives Methods Results Discussion FactorsOR95% CI Ethnicity Kikuyu1 Kamba1.5[1.1 - 2.2] Luha2.2[1.4 - 3.4] Luo2.1[1.5 - 3.1] Symptoms Score 01 Score 12.1[1.1 - 4.3] Score 29.4[5.8 - 15.5] Score 313.6[8.4 - 22.1] Score 414.9[8.8 - 25.3] Score 5+23.7[13.0 - 43.2] Risk associated with Self-diagnosed Malaria FactorsOR95 %CI Slums Korogocho 1 Viwandani1.6[1.1 - 2.3] Sex Female 1 Male1.1[0.9 - 1.5] Age group (yrs) <5 1 5-141.0[0.7 - 1.6] 15-241.3[0.9 - 2.0] 25-392.1[1.4 – 3.0] >401.3[0.9 - 2.0] Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

18. High level of self-diagnosed-malaria Expected high use of anti-malarial drugs Risk of development of drug resistance Wastage of scarce resources Background Objective Methods Results Discussion Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

19. Risk factors suggest imported malaria High risk among age group 25-40 yrs High risk among Luo’s and Luyha from high risk areas High risk in Viwandani where there is high mobility Background Objective Methods Results Discussion Imported Malaria? Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

20. Locally acquired malaria cannot be ruled out Significant proportion of the so-called stable population had reported malaria Nairobi is not a malaria free zone though the transmission may be low Background Objective Methods Results Discussion Locally Acquired Infection? Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

21. Self reported approach for assessing malaria? However, very few (5.8%) reported malaria without fever ↑ number of symptoms was associated with ↑ risk of perceived malaria Fever was the basis of reporting malaria Background Objective Methods Results Discussion Reliability of Self-diagnosed Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007

22. Malaria is perceived as a problem by the community of the informal settlements Whether misdiagnosis or imported, there is a cause for concern for National control programs Need for a more comprehensive assessment of malaria epidemiology Background Objective Methods Results Discussion Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007 Key Messages

23. Parasite prevalence surveys Data on fever could be routinely collected History of travelling should be collected Background Objective Methods Results Discussion Conclusion INDEPTH Network AGM 2007, September 3 rd -7 th, 2007 How can DSS help?

24. Thank you for your attention!!! Yazoumé Yé, Elizabeth Kimani-Murage, John Kebaso and Frederick Mugisha. Assessing the risk of self-diagnosed malaria in urban informal settlements of Nairobi using self-reported morbidity survey. Malaria Journal 2007, 6:71 Further reading: