Prevalence of Malaria and Associated Factors among Febrile Children Under 15 Years at Bududa General Hospital, Eastern Uganda

doi:10.21203/rs.3.rs-5328245/v1

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Prevalence of Malaria and Associated Factors among Febrile Children Under 15 Years at Bududa General Hospital, Eastern Uganda

https://doi.org/10.21203/rs.3.rs-5328245/v1

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Background

A considerable number of malaria-related deaths occur in Africa, with Uganda being one of the endemic nations where malaria continues to pose a public health challenge. This study aimed to determine the prevalence of malaria and its associated factors among febrile children under 15 years of age at Bududa General Hospital, Eastern Uganda.

Methods

This cross-sectional study was conducted between April and June 2023. Informed consent was obtained from parents/guardians before 250 febrile children below 15 years were enrolled in this study. A structured questionnaire was administered to parents/guardians to collect sociodemographic characteristics and identify factors associated with malaria. Venous blood samples were collected from the children and screened for the presence of malaria parasitaemia using via blood smear microscopy. The data collected were entered into an Excel spreadsheet and analysed using STATA version 14. Logistic regression models were developed to determine the factors associated with malaria, and we considered ≤ 0.05 as the level of significance.

Results

Out of the 250 study participants, the overall prevalence of malaria was 111(44.4%). Among the children who tested positive for malaria, 98 (88.3%) had Plasmodium falciparum, 11 (9.9%) had Plasmodium malariae, and (1.8%) had Plasmodium ovale infection. The mean parasite count was 21,951 parasites/µL of blood. The prevalence rates of mild, moderate, and severe malaria parasitaemia were 46.8%, 28.0%, and 25.2%, respectively. In the multivariate analysis, the factors associated with malaria infections were older age; 1 to 5 years (p = 0.013), 6 to 10 years (p = 0.000), 11 to 15 years (p = 0.000), secondary education level of parent/guardian (p = 0.050), and no use of insecticide-treated bed nets (p = 0.002).

Conclusion

The prevalence of malaria among febrile children in this study was high, with nearly half of the participants showing severe infections. Health education on the correct use of insecticide-treated mosquito nets should be prioritized to help control malaria.

Prevalence

malaria

factors

febrile

children

Uganda

Malaria remains a public health problem with the highest burden in the African Region of the World Health Organization (WHO). Globally, in 2022, there were 249 million malaria cases, and the WHO African Region accounted for 94% of the cases (1). This same report also indicated that Nigeria (27%), the Democratic Republic of Congo (12%), Uganda (5%) and Mozambique (4%) accounted for almost half of the total global malaria cases (1).

In Uganda, malaria is the foremost cause of morbidity and mortality, and a recent publication acknowledged that it led to 29.1% outpatient visits, 39.5% inpatient admissions, and 10.9% hospital deaths (2). According to reports, between December 2018 and February 2019, the nationwide prevalence of malaria in children under five years old was 9%. The majority of cases were caused by Plasmodium falciparum, with the remaining cases being caused by Plasmodium malariae (10%), Plasmodium ovale (2%) and mixed infections (9%) (3). Limited information is available in Uganda regarding the frequency of malaria in children under the age of 15, but a report published in the malaria consortium 2023 states that children between the ages of 5 and 15 are susceptible to malaria, frequently without any accompanying symptoms, which can impede efforts to eradicate the parasite and spread it further (4).

Several studies have also been conducted by scholars within the country among children under 5 years in recent years; a 76% prevalence of malaria among children under five years of age was reported in two general hospitals in Karamoja (2), and another study reported a 23.3% prevalence of malaria among children under five years of age in the whole country on the basis of evidence from the previous 2018–2019 Uganda Malaria Indicator Survey (5). Despite the malaria control measures put by the Ministry of Health, such as the distribution and use of insecticide-treated mosquito nets, intermittent preventive treatment of malaria during pregnancy and indoor residual spraying, malaria remains a public health challenge among children in Uganda (3). The utilization rate of LLITNs in Africa remains considerably low, although a small segment of the population uses them regularly. The key reasons for not using nets include discomfort from heat and concerns about the chemicals they contain (6, 7).

In addition, the prevalence of malaria among children under 5 years of age in the Bugisu sub-region was reported to be 5% (3), and scarce information exists about malaria in Bududa General Hospital; however, the increased cases of malaria from April to June 2023 at this facility called for this cross-sectional study. Continuous studies are necessary if Uganda is to meet the malaria control target; therefore, this study aimed to determine the prevalence of malaria and associated factors among children under 15 years of age at Bududa General Hospital, Eastern Uganda, and address the above gaps.

Study site

This was a cross-sectional study carried out at Bududa General Hospital, a public healthcare institution in the district of Bududa in the Bugisu sub-region in Eastern Uganda. It is located approximately 38 kilometers southeast of Mbale city. The coordinates of Bududa General Hospital are 01°00'34.0"N latitude and 34°19'58.0"E longitude. The hospital has 100 beds and offers a variety of medical services, including inpatient and outpatient treatment, maternity care, surgical services, laboratory services, and pharmacy services. It also provides HIV/AIDS testing and counselling, immunization, and family planning.

Study Design

This cross-sectional study was conducted between April 2023 and June 2023. The choice of this study period was primarily the increased number of malaria cases among children at Bududa General Hospital in the abovementioned months, which could be influenced by the climatic conditions of Bududa District and neighboring areas since previous malaria surveys were conducted between December 2018 and February 2019.

Study population

Febrile children below 15 years at Bududa General Hospital.

Inclusion criteria

Age below 15 years
Fever ≥ 37.5°C in the past 48 hours
Parents/guardians provided written informed consent for participation.

Exclusion criteria

Non-febrile children
Children with chronic or congenital Illnesses (e.g., sickle cell disease, HIV/AIDS)
Children already receiving anti-malarial treatment
Children with recent malaria diagnosis (e.g., within the last two weeks)
Severe Acute Illness (e.g., bacterial infections, viral illnesses).
Children on long-term Prophylaxis for malaria

Sample size calculation

The required sample size for enrolment was estimated the Kish and Leslie formula for a single population proportion on the following assumptions: a malaria prevalence of 19.7%, a 95% confidence level, and a 5% marginal error. This estimation was informed by a study conducted in Uganda (8). The formula for calculating the sample size for proportion was as follows:

where n = the desired sample size.

Z = critical value of the normal distribution at 95%, which corresponds to 1.96

P = the proportion of the target population estimated to have malaria.

d = estimated margin of error 5%

n = 243

Hence, this study recruited 243 study participants, but we collected data from 250 study participants.

Sampling procedure

A simple random sampling method was used to recruit the participants, and those who declined were excluded. Participants were assigned folded papers with numbers written inside ranging from 1–40, and anyone who selected an even number was enrolled in the study until the calculated sample size was achieved.

Data collection

Informed consent

was obtained from the parents/guardians of the children who met the inclusion criteria, and a structured questionnaire was administered to the parents/guardians to collect their sociodemographic characteristics and identify factors associated with malaria. Approximately four millilitres (4 ml) of venous blood samples were collected from the children in an ethylene-diamine-tetraacetic acid (EDTA) vacutainer and screened for the presence of malaria parasitaemia using blood smear microscopy method. Thick and thin blood smears were prepared, stained with Giemsa stain and examined at ×1000 magnification for malaria parasite detection, species identification and parasite counting. Parasite density was determined by counting the number of malaria parasites present and the number of white cells present simultaneously. Counting was stopped when ≥ 100 parasites in 200 white cells were counted or if ≤ 99 parasites in 500 white cells were counted. The parasite density was then calculated by dividing the number of parasites by the number of white cells counted and multiplying by 8000 and reported as parasite/µL of blood according to WHO guidelines (9).

The parasite density was classified as mild (parasite number = 5–10,000/µL of blood), moderate (parasite number = 10,000–100,000/µL of blood) or severe (parasite number > 100,000/µL of blood) (10). Participants with positive results were referred to physicians for management.

Quality control

A standard operating procedure (SOP) was employed and followed at each step of the testing process to ensure data quality. Structured questionnaires and a checklist were pretested for appropriateness. The Giemsa stain working solution was freshly prepared daily. Furthermore, the glass slides were labelled with the study participants’ unique code numbers. A sterile, single-use syringe was used for each child during blood sample collection, and the smears were reviewed by a WHO-certified malaria microscopist.

Data analysis

The data collected were entered into an Excel spreadsheet and analysed using STATA software version 14.0. Categorical data and continuous variables are presented using descriptive statistics in the form of percentages, frequencies and pie-chart. Associations between malaria prevalence and factors were determined using bivariate logistic regression analysis. Factors with p values less than or equal to 0.1 in the bivariate analysis were subjected to multivariate logistic regression analysis. Factors with p values ≤ 0.05 were considered statistically significant.

Demographic characteristics of the study participants

This study enrolled 250 study participants. The mean age was 6.2 years (SD = 4.95 years). The majority of the study participants were aged between 1 and 5 years (37.6%), were females (54%), were living in rural areas (89.6%), had parents/guardians who had attained secondary education (57.2%), and peasant farmers (72%), as shown in (Table 1).

Table 1

Socio-Demographic Characteristics of study Participants
Variables		Frequency (n)	Percentage (%)
Age (years)	< 1	36	14.4
	1–5	94	37.6
	6–10	53	21.2
	11–15	67	26.8
Sex	Male	115	46.0
	Female	135	54.0
Residence	Rural	224	89.6
	Urban	26	10.4
Education level of parent/guardian	Primary	100	40
	Secondary	143	57.2
	Tertiary	7	2.8
Occupation of parent/guardian	Business	21	8.4
	Peasant	180	72
	Others	49	19.6
Household income	<Ugx. 100,000/=	107	42.8
	≥Ugx. 100,000/=	143	57.2
Number of children in household	≤ 4	227	90.8
	> 4	23	9.20
Distance to hospital	≤ 2km	99	39.6
	> 2km	151	60.4
Ugandan Shillings (Ugx)

Prevalence of malaria

The overall prevalence of malaria was 111 (44.4%) among children aged less than 15 years at Bududa General Hospital (Fig. 1). Among the children who tested positive for malaria, 98 (88.3%) had Plasmodium falciparum, 11 (9.9%) had Plasmodium malariae and 2 (1.8%) had Plasmodium ovale infection. The mean parasite count was 21,951 parasites/µL of blood, The prevalence rates of mild, moderate, and severe malaria parasitaemia among children with malaria were 52 (46.8%), 31 (28.0%), and 28 (25.2%), respectively.

Factors associated with malaria infection

The associations between malaria prevalence and various factors (age, sex, education level of parents/guardians, use of insecticide-treated mosquito nets, stagnant water around the home, household income, number of children in the household, type of housing, residence, occupation of parents/guardians, history of malaria infection, and staying outside at night) were assessed using logistic regression analysis. In the bivariate analysis, older age (1–5 years (p = 0.008), 6–10 years (p = 0.000), and 11–15 years (p = 0.000)) and not using insecticide-treated mosquito nets (p = 0.001) were significantly associated with malaria (Table 2).

Table 2

Bivariate analysis of factors associated with malaria
Variables		Odds ratio	95% Confidence interval	P value
Age (years)	< 1	Ref
	1–5	4.01	1.43–11.27	0.008^*
	6–10	10.79	3.63–32.06	0.000^*
	11–15	6.93	2.38–20.23	0.000^*
Sex	Male	Ref
	Female	1.15	0.64–2.06	0.640
Occupation	Business	Ref
	Peasant	0.88	0.28–2.76	0.830
	Others	0.94	0.28–3.15	0.920
Traveling history	No	Ref
	Yes	0.69	0.27–1.74	0.427
Residence	Rural	Ref
	Urban	1.66	0.57–4.84	0.351
Number of household children	< 4	Ref
	≥ 4	0.79	0.29–2.16	0.642
Distance to hospital	≤ 2km	Ref
	> 2km	0.79	0.42–1.48	0.462
Housing	Permanent with screen	Ref
	Permanent without screen	0.30	0.06–1.49	0.140
	Semi-permanent with screen	0.84	0.31–2.28	0.736
	Semi-permanent without screen	0.33	0.11–1.04	0.056
Education level	Primary	Ref
	Secondary	1.73	0.89–3.37	0.107
	Tertiary	0.71	0.09–5.70	0.747
Household income (Ugandan shillings)	< 100,000/=	Ref
	≥ 100,000/=	0.63	0.33–1.20	0.161
Stay outside at night	No	Ref
	Yes	1.36	0.64–2.86	0.424
Stagnant water	No	Ref
	Yes	1.48	0.41–5.33	0.549
Use of Insecticide treated mosquito net	Yes	Ref
	No	3.78	1.75–8.12	0.001^*
Significant ^*

According to multivariate analysis, individuals aged 1–5 years (p = 0.013), 6–10 years (p = 0.000), and 11–15 years (p = 0.000) had a greater risk of malaria infection than younger individuals did (< 1 year). Additionally, children of parents/guardians who had attained secondary education (p = 0.050) were at greater risk of malaria infection than were children of parents who had attained primary education. Finally, children who were not using insecticide-treated mosquito nets (p = 0.002) were at greater risk of suffering from malaria than were children who were sleeping under insecticide-treated mosquito nets (Table 3).

Table 3

Multivariate analysis of factors associated with malaria
Variables		Adjusted Odds ratio	95% Confidence interval	P value
Age (years)	< 1	Ref
	1–5	3.47	1.30–9.27	0.013^*
	6–10	9.60	3.35–27.60	0.000^*
	11–15	6.34	2.30–17.49	0.000^*
Education level	Primary	Ref
	Secondary	1.84	1.00–3.37	0.050^*
	Tertiary	1.10	1.18–6.63	0.919
Insecticide treated mosquito net usage	Yes	Ref
	No	2.93	1.48–5.84	0.002^*
Household income (Ugandan shillings)	< 100,000/=	Ref
	≥ 100,000/=	0.62	0.34–1.12	0.110
Note: ^* Significant factor

The prevalence of malaria among febrile children under 15 years of age in the present study was 44.4%, with prevalences of mild, moderate, and severe malaria of 46.8%, 28.0%, and 25.2%, respectively. The overall prevalence of malaria revealed in this study differs from the findings of the Uganda Malaria indicator health survey, which reported that the prevalence of malaria among children under 5 years of age was 9% and 5% in the Bugisu region (11). Several other studies conducted within Ugandan reported 19.04% (12), 19.7% (13), 23.3% (5) and 76% (2) prevalence of malaria among children under 5 years of age. The possible explanations for this observation could be differences in age specifics. The Uganda Malaria Indicator Health Survey focused on children under 5 years, while our study examined children under 15 years. Other reasons of the differences in findings could be the access to and use of insecticide-treated mosquito nets, differences in the malaria peak for different regions in Uganda, differences in vector density due to rainfall patterns and temperatures, changes in biting patterns, which are now both indoors and outdoors, parasite variations (Plasmodium falciparum, Plasmodium malariae and Plasmodium ovale), drug resistance, the type of housing and vegetation density and all these factors influence mosquito breeding, infective mosquito bites, and malaria infection recurrence or recrudescence.

This study's findings were also incompatible with previous findings, which reported prevalences of 12.2% (14) and 14% (15), respectively, in Rwanda. Several studies reported rates of 24.6% (16), 22.1% (17), 14.7% in Ethiopia (18), and 33% in Malawi (19). The variation in prevalence could be due to diagnostic criteria, sample size differences, geographical disease distribution, study design, health-seeking habits, and the socioeconomic status of these children's parents. Our findings, however, were closely comparable to the reported prevalence rates of malaria of 36.6% in Uganda (20), 44% in Guinea (21), and 37% in Malawi (22).

Plasmodium falciparum infection was the most common malaria infection among the children in the current study. Other species reported in the present study also include Plasmodium malariae and Plasmodium ovale infections. This finding is in line with reports from the Uganda Malaria Indicator Health survey, which also reported Plasmodium falciparum infection to be the most common malaria infection, followed by Plasmodium malariae and Plasmodium ovale infections, among children (3). The emergence of plasmodium malariae and ovale in Uganda poses a challenge for the region, as the detection of these species, in addition to Plasmodium falciparum, requires specialized training for laboratory microscopists.

Our study revealed that older age was associated with malaria infection and that children who were older were more likely to suffer from malaria. Although we recruited participants with fever, the above finding is comparable with two studies conducted in Uganda, which reported a similar finding that older age is a predictor of malaria among children under 15 years of age (5, 12), and in Kenya (23). This observation has been attributed to the age related immunity that develops in these children because of continuous exposure to infective mosquito bites, and this immunity develops first against complicated malaria, then to uncomplicated malaria and to malaria parasitemia, explaining the high prevalence of malaria parasitemia among older children but without them developing clinical disease (24). The malaria consortium 2023 highlighted that one of the new challenges posed by global malaria trends is the shifting epidemiological patterns in at-risk populations, which include children aged 5 to 15 who are more likely to have malaria without symptoms and who are also less likely to use mosquito nets and receive treatment (4).

This study also reported that parents’/guardians’ secondary level of education was associated with high malaria parasitemia. This finding is not in agreement with a finding of a study in Uganda that revealed an association between the primary and tertiary education levels of the child’s parents or guardians and a lower risk of malaria infection (12). Other studies were also not in agreement with our findings about parents’/guardians’ education (22, 25). However, parent/guardian education attainment is associated with higher socioeconomic status, a wealthier household, and a better life, which leads to a reduced risk of developing malaria infection (12). Parents and guardians who had not received health education in the past 6 months were more likely to have children suffering from malaria due to the knowledge gap in disease control and prevention (16), which still elaborates on the significance of parent/guardian education in influencing their children’s health.

Children who were not sleeping under insecticide-treated mosquito nets were 2.93-fold more likely to develop malaria parasitemia than were those who were sleeping under insecticide-treated mosquito nets. This finding was in line with a study that reported a 15-fold increase in the risk of developing malaria among children who were not sleeping under insecticide-treated mosquito nets (14). This study was also in agreement with studies that linked malaria infection with irregular utilization of insecticide-treated bed nets, and the probable explanation was continuous exposure to infective mosquito bites that can lead to malaria infection (16, 25).

In Africa, mosquito-treated bed nets have shown to be a crucial intervention in the fight against malaria, especially for susceptible groups like expectant mothers and children. Misuse (Figs. 2, 3, 4 and 5), however, has the potential to cause loss of efficacy and environmental deterioration. Community leaders, health groups, and governments must prioritize correct utilization and establish alternative resources for activities like fishing or crop protection to guarantee bed nets remain dedicated to their primary role in malaria prevention (26).

On the basis of the study results, malaria remains a significant public health issue, with an overall prevalence of 44.4%, with almost half of the study participants having a severe form of malaria. Age, the mother's secondary education level, and failure to use insecticide-treated bed nets were identified as significant factors associated with malaria infection. These findings underscore the need for targeted interventions, such as promoting the use of bed nets and increasing awareness of malaria prevention, particularly in vulnerable age groups and less educated populations.

Limitation of the study

This study utilized a cross sectional study design and it was a hospital based study and it limits its generalizability to other regions.

Ethics approval and consent to participate

This study was approved by the Faculty Research Committee (FRC), Faculty of Medicine, Mbarara University of Science and Technology, and the office of the Hospital Director, Bududa General Hospital (Approval number MUST/MLS/030).

Consent for publication

Informed consent was obtained from the parents/guardians of the children, and they were assured of confidentiality. The purpose of the study was explained to them that their participation was free and voluntary and that they were free to withdraw from the study at any time and would not affect their access to medical attention.

Funding

No financial support received for this study.

Acknowledgements

The study acknowledges the invaluable support and cooperation of participants, hospital administration and medical staff of Bududa General Hospital in making this research possible, your unwavering support throughout the data collection process greatly facilitated the research. The successful completion of this study would not have been possible without the collaboration and generosity of everyone involved.

Author contributions

BO: Conceived the study, conducted data collection, performed data analysis, drafted the manuscript, and provided final approval for the submitted version. DA: Conceived the study, conducted data collection, CO: Performed data analysis and manuscript drafting. RW and EM: Conceived the study, conducted data collection, and manuscript drafting.

Data availability

The data are available upon request from the corresponding author.

Competing interests

“The author(s) declare(s) that they have no competing interests”.

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Prevalence of Malaria and Associated Factors among Febrile Children Under 15 Years at Bududa General Hospital, Eastern Uganda

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Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Materials and methods

Study site

Study Design

Sample size calculation

Sampling procedure

Data collection

Data analysis

Results

Demographic characteristics of the study participants

Prevalence of malaria

Factors associated with malaria infection

Discussion

Conclusion

Limitation of the study

Declarations

References

Additional Declarations

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