Asymptomatic malaria: refers to the presence of malaria parasite in the blood without symptoms, which usually provides a reservoir for transmission.

Knowledge: refers to awareness or familiarity gained by experience of a fact or situation

Prevalence: refers to the number of cases of a disease that present in a particular population at a given time.

Reservoirs: refers to the population of organism or the specific environment in which an infectious pathogen naturally lives and reproduces.

Risk factors: refers to condition that increases a person’s chances of developing a disease.

ABSTRACT

Background; Malaria prevalence continues to decline in Tanzania following the results of various intervention strategies which has lowered down the prevalence of malaria to less than 10%. However, the disease still poses a public health concern in the country. While symptomatic malaria is recognized and treated, asymptomatic malaria infections become increasingly important for interrupting transmission. Following the decline of malaria in Tanzania, it is not known how much the epidemiology of asymptomatic malaria have changed in Bagamoyo district particularly among primary school children. Therefore, this study will be conducted to determine prevalence and risk factors of asymptomatic malaria among school children in Bagamoyo district

Objective: The aim of this study is to determine the prevalence and risk factors of asymptomatic malaria among of school children in Bagamoyo district.

Methodology: A descriptive cross-sectional study will be conducted using quantitative methods of data collection. A multistage sampling will be used to obtain 305 school children required for this study. Finger prick blood sample will be collected for detection of malaria parasite, this will be complimented with questionnaire that will be used to determine the risk factors of asymptomatic malaria and prevention methods among school children. Data will be entered into SPSS software version 24 to obtain frequency and their 95% CI, association between variables will be assessed using Chi-square test at the significance of 0.05%.

Budget: The grand total of TSH 1,002,650/= is expected to be used for running all research activities. This amount will cover costs for stationary, materials and allowances.

Time frame: The study will commence on December 2019 and it will end on September 2020.

CHAPTER ONE

1.0. INTRODUCTION

1.1 BACKGROUND

Malaria is a disease of tropical and sub-tropical which is transmitted by vector known as female anopheles’ mosquito. It is caused by Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale and Plasmodium vivax. Among the five species of Plasmodium; Plasmodium vivax and Plasmodium falciparum are responsible for most malaria attributed morbidity(1).

Malaria can be of either symptomatic or asymptomatic. Asymptomatic malaria refers to the presence of malaria parasites in blood without any clinical symptoms usually asymptomatic individuals serve as the reservoir for transmission (1). Asymptomatic malaria can be analyzed and detected by microscopy, rapid diagnostic test and molecular methods (1). For the case of symptomatic malaria; infection is accompanied by fever, chills, headache, nausea, vomiting, diarrhea, and extreme weakness and muscles aches (1). Whether its asymptomatic or symptomatic malaria, Plasmodium falciparum accounts for most malaria mortality which mainly occur in children under the age of 5years in sub-Saharan Africa (1).

Plasmodium species have complex life cycle that involves transmission between a mosquito vector and human host. The life cycle of Plasmodium species undergoes three reproductive stages(2) and the malaria parasite life cycle involves two hosts.

The life cycle starts when a malaria infected female anopheles’ mosquito inoculates sporozoites into the human host, these sporozoites invade the liver cells which mature and finally releases merozoites, then relapses by invading the bloodstream after weeks or even years letter the parasite undergo multiplication in the erythrocytes. Merozoites infect red blood cells while some parasites differentiate into sexual erythrocytic stage which are male and female gametes, both microgametocytes (male) and macro gametocytes (female) are ingested by anopheles’ mosquito during blood meal, the parasites multiply into mosquito’s stomach which is called sporogonic cycle. This results into the development of zygotes which invade the midgut wall of the mosquito where they develop into oocytes, the oocytes grow, rapture and release sporozoites which makes their way to the mosquito’s salivary glands. Inoculation of the sporozoites into a new human host perpetuates the malaria life cycle (1).

Malaria parasites can be identified by examining under microscope which is the gold standard for diagnosis. Other diagnostic techniques include rapid diagnostic test (RDTs) and Polymerase chain reaction (PCR)(3).

In Tanzania mainland’s national guidelines for diagnosis and treatment of malaria stipulate artemether–lumefantrine (ALu) as the first line treatment for uncomplicated malaria in both adults and children (4).

1.2 Global burden of malaria

In the past decades, intensive malaria interventions have resulted in a dramatic decline in global malaria morbidity and mortality (7). However, the global burden of malaria is still enormous. Between 2015 and 2018, only 31 countries were still malaria endemic. Due to this ongoing burden of malaria, the global technical strategy for malaria 2016 - 2030 was endorsed by World Health Assembly (WHA). The plan aimed for reduction of global incidences and mortality of malaria by at least 90% by 2030.

According to WHO (2018), Plasmodium falciparum accounted 99.7% of all malaria cases and 50% of cases were from South East Asia region ,71% cases were from Eastern Mediterranean and 65% were from the Western Pacific.

WHO reported that there has been variation of malaria prevalence and incidence globally. In 2018 it was estimated that 228 million cases of malaria occurred worldwide. Most of the cases were in African region (93%) followed by South-East Asia region with 3.4% and 2.1% in Eastern Mediterranean region. Despite the ongoing burden, the incidence rate of malaria has declined globally between 2010 and 2018 from 71 to 57 cases per 1000 population at risk(5).

Asymptomatic malaria is prevalent in both low and high endemic regions. The asymptomatic carriers play important role as reservoirs for sustaining malaria transmission because they persist for long time and harbor gametocytes that are infections to anopheles mosquito (6).

1.3 Burden of malaria in Tanzania

Tanzania has the third largest population at risk of malaria in Africa. Malaria is highest in the kagera region with prevalence of 8.8% on western shore of Lake Victoria and lowest in Arusha region which is less than 0.1 %(7).

Malaria prevalence in Tanzania has decreased by half from 14.4% in 2016 to 7.3% in 2018 said by National Bureau of Statistics (NBS) the report also showed that new infections for children under the age 5 have dropped to 7.3% in 2017. Also, the numbers of children dying with malaria were halved in 2018(8).

Furthermore, the prevalence of malaria in rural areas was 10% and in urban was 2% (9). Despite the decline of malaria case in some areas of Tanzania still have more than the named prevalence, such as Kigoma which has the prevalence of 24%, Geita 22.4%, Buhingwe 24%, Melba 19.4%. The survey also named that more than 10 councils has prevalence of less than 0.1% just to name the few Moshi DC, Mwanga DC, Meru DC, Monduli (8).

In Bagamoyo district where this study will be conducted, incidence rate is under 10% which has declined from 80% in two decades ago. Also, in 2017, it was observed that the prevalence of asymptomatic malaria to be 14% which indicate that there is percent of community members who serve as the reservoir of infection (11). Therefore, this study aims to determine the current prevalence of asymptomatic malaria and risk factors among of school children in Bagamoyo district.

1.4 Problem statement

Malaria is still a public health and life-threatening disease in Tanzania. The vulnerable group being infants, children under 5 years’ age, pregnancy women and patients with HIV/AIDS. School children are not included as the one of the vulnerable groups to malaria. However recent studies have showed that the burden of malaria has shifted from under 5 years age to children between 7 to 13 years(10)

A study conducted in 2017 on asymptomatic malaria among under-fives and school children in Bagamoyo district showed that the prevalence of asymptomatic malaria was 14% which is tremendous higher compared to the data of TMIS (2018) that showed the prevalence to be 7.4%(11). This clearly show that the high prevalence is the problem because the asymptomatic carriers will serve as the reservoir for infection hence continual transmission of malaria. Also the asymptomatic carrier will pose a challenge in control and elimination of the malaria hence there is a need to conduct this study in order to investigate the risk factors that can lead to asymptomatic malaria. Therefore, this study will be conducted to determine prevalence and risk factors of asymptomatic malaria among school children in Bagamoyo district

1.5 Conceptual framework

Prevalence of asymptomatic malaria

Social demographic characteristics

· Age

· Sex

· Class level

Risk factors for A. malaria

· Gender

· Age

· Bed net usage

· Indoor spraying

· Repellants

Knowledge on malaria

· Transmission

· Causative agent

· Sign and symptoms

· Treatment

· Prevention

· controls

Malaria prevention techniques

· Use of repellants

· Closed doors

· Screened window

· Protective clothes

· Use of ITNs

· LLINs

Figure 1. The conceptual framework showing the prevalence of asymptomatic malaria, malaria preventive techniques, knowledge on malaria, social demographic characteristics and risk factors on asymptomatic malaria.

Description of the conceptual framework

The conceptual frame work shows that, social demographic characteristics such as age, sex and class level have direct relationship with asymptomatic malaria. Those females may be at high risk of having asymptomatic malaria compared to males because in some families females do the household chores such us cooking which sometimes exposing them to mosquitos while males remain indoors. Also children aged from 11 to 14 years might have high prevalence to asymptomatic malaria than those with age less than 10. However, children who use protective measures such as bed net usage; indoor spraying and repellants have less chance to develop asymptomatic malaria than those who did not use. Usage of those protective measures might be related to ages and class level that those of low ages below 10 receive close care from their parents hence higher chances to sleep under nets.

Along that, children with knowledge on malaria causatives, prevention and control may have less chance to develop asymptomatic malaria than those with no knowledge; this level of knowledge is also related with class level and ages.

1.6 Research questions

1. What is the prevalence of asymptomatic malaria among school children in Bagamoyo district?

2. What are the risk factors associated with asymptomatic malaria among of the school children in Bagamoyo district?

3. What is the level of knowledge among of school children on malaria in Bagamoyo district?

4. What is a portion of students using different malaria prevention methods in Bagamoyo district?

1.7 Objectives

1.7.1 Broad objective

The broad objective is to determine prevalence and risk factors of asymptomatic malaria among school children in Bagamoyo.

1.7 .2 Specific objectives

To determine prevalence of asymptomatic malaria among school children in Bagamoyo district.
To determine risk factors associated with asymptomatic malaria among of the school children in Bagamoyo district.
To determine the level of knowledge among school age children on malaria in Bagamoyo district.
To determine the portion of students using different malaria prevention methods in Bagamoyo district.

1.8 Rationale

The rapidly shrinking malaria map takes us a step closer to the worldwide malaria eradication, yet a great challenge remains to achieve and promptly eliminates malaria. Data collected will provide current burden of asymptomatic malaria in Bagamoyo which will help in planning of effective strategies to strengthen malaria intervention methods to group of school age children so that to attain the goal of malaria elimination.

CHAPTER TWO

2.0. LITERATURE REVIEW

Asymptomatic malaria refers to an individual who harbor malaria parasites such as Plasmodium falciparum but do not presents clinical symptoms of the disease (2). In malaria – endemic countries, a large proportion of P. falciparum are asymptomatic or sub- clinical (1). Asymptomatic carriers do not seek treatment for their infection, and therefore constitutes a reservoir parasite for newly hatched mosquitoes which then confer to transmission of the disease (3).

Patients with asymptomatic Plasmodium falciparum infection, especially children under five and school aged usually experience increase in morbidity due to anemia and reduced cognitive developments (4). The detection and treatment of asymptomatic carriers of Plasmodium parasites is one of the innovative strategies for malaria control and it has been previously considered and included in the WHO guidelines for treatment of malaria (3). Distribution of malaria chemoprophylaxis to African school children is accompanied with lower rates of malaria parasitemia and severe anemia, few clinical attacks and reduced school absenteeism due to malaria (5).

2.1 Prevalence of asymptomatic malaria among school children.

The prevalence of asymptomatic malaria varies in different regions around the global thus to say the prevalence of asymptomatic infection is not uniformly (1).

A community study conducted in Molyko, Cameroon to determine the prevalence of asymptomatic malaria among school children in an urban and rural areas, showed that out of 116,158 school children recruited in both urban and rural areas, the prevalence of asymptomatic malaria infection was 42.17% and 40.16% respectively(12). This shows that there was lack of significant difference in prevalence between the two areas. School age children harbor malaria parasite of whether they are from rural or urban. Control measures are therefore, urgently needed to reduce the burden of the disease(12).

Another study conducted in Bova, Cameron to determine the prevalence of asymptomatic malaria among school children in rural and urban settings (during both dry and rainy season), the results indicated that out of 112 and 117 school age children the prevalence was in 42% and 44% respectively (6). This clearly shows lack of a significant difference between the two seasons which implies perennial transmission of the disease in the area. Also a study conducted in Ethiopia to determine the prevalence of asymptomatic malaria among school children and associated risk factors showed that out of 385 school children recruited, the prevalence was 22% % in both male and female(13). Furthermore, the prevalence of asymptomatic malaria decreased with the increase of age group.

In Kiwangwa, Bagamoyo district, Tanzania, it was observed that prevalence of asymptomatic malaria among of school age children was 14% in 2017(2). This pick tells that there was higher gametocytaemia in asymptomatic children which indicates the reservoir infections and points to the need for detection and treatment of both asymptomatic and symptomatic malaria.

2.2 Risk factors associated with asymptomatic malaria among school children

A study done by (7) to determine the risk factors associated with asymptomatic malaria among of school children in Sanja town. The results showed that males were significantly more likely than female to have asymptomatic infections with prevalence of 9.8% and 5.4% respectively. The age group of less than 15 years had significantly higher odds of malaria infection. Also, the effect of vector control-based preventive measures where very remarkable. Furthermore, those who did not sleep under nets had more than 5 times higher odds of asymptomatic malaria infection than those who did.

School children from the households that did not have IRS had 34 times higher odds of asymptomatic infections than those with IRS. Furthermore, major building materials of the houses reflected the economic status of the family, also showed significant effect on asymptomatic malaria infections. Those families which their houses are not well ventilated had approximately twice the odds of having asymptomatic malaria. Finally, longer distance of household to the nearest clinic >180m was also significantly associated with higher risk of malaria infection (8). This indicates that there is the need to do further evaluation on the burden of asymptomatic malaria by considering age groups, sex, and malaria transmission level to scale up the elimination and eradication program of malaria among school children. Also, these findings provide the needed of providing health education for guiding the malaria control and elimination program in given certain area for combating the asymptomatic infections among school children.

A study conducted in Tanzania showed that school children who used Artemisinin –based combination therapy (ACT) in combination with insecticide –treated nets (ITNs), long –lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) had low risk of developing malaria and seems to be most aggressive methods for reducing malaria burden in endemic region(14).

2.3 Knowledge on malaria among school children

Several studies have been done to investigate level of knowledge on malaria, affordability and accessibility of ITN are among major obstacles for the ITN ownership and use (3) Net ownership has also been related to education level of household members, which it’s a complicated relationship because education attainment can have the impact on individual’s ability to understand and access information regarding malaria prevention (9).

Some survey reveals a lack of knowledge and many misconceptions about the transmission, treatment of malaria, control measures and antimalarial therapy as a knowledge gap could have an advance effect on school children who could be used as change agents and role models for their siblings and peers in malaria control strategy. Thus, there is a need to empower teachers with information about the cause of malaria and preventive strategies (9).

Furthermore, knowledge among school children on the sign of malaria such as high temperature followed by headache, nausea and body weakness is said to vary from one school children to another (4).

Authors in Tanzania(15), revealed 63% of schoolchildren aged 6-14years assessed to determine who have knowledge on malaria transmission and recognized that about 8% of schoolchildren didn’t understand the type of malaria mosquito that transmit malaria and 5.6% had misconception about malaria transmission, some children knew that malaria is caused by eating dirty food, contact with malaria patients and going to the toilet without shoes.

False knowledge and misconceptions on causes of malaria will continue to increase the incidences and prevalence of malaria among schoolchildren since they are not able to implement correct preventive measures of malaria.

However, a study performed in Morogoro Tanzania revealed that 99% (395) of the recruited children had knowledge on malaria transmission methods and used protective measures such as long clothes and ITNs, also mass media and teachers was the source of knowledge used in more than half of the recruited children. This tell us that knowledge of school children can be associated with the community surrounding them(14).

2.4 Malaria prevention methods for school age children.

The practice of malaria preventive measures has been related to the level of knowledge and belief of people. The understanding of the possible causes, mode of transmission and decision about the mode of adoption of preventive and control measures vary from community to community among individual households (10). The current emphasis on malaria control is centered on community-based strategies. In order to prepare for a successful malaria control program, it is necessary to evaluate the level of knowledge and practice of people living at risk area. (10). the majority of malaria cases are acquired via a bite from an infected mosquito, although some cases are acquired transplacentally or via transfusion of blood products. Generally, to avoid malaria infection, school age children must avoid being bitten by an infected mosquito. This can be accomplished by controlling physical environment, blocking mosquito access to the skin, repelling mosquito from skin(16).

Mosquito bites can be avoided by use of appropriate environmental control such as closing doors and use of house with screened window and use of protective clothing that is skin should be covered with clothing (lightweight for comfort and light-colored to be less attractive to insects), sleeping children should be surrounded by nets, repellents, and insecticide(17).

Poor practice of malaria prevention may be linked to various factors as lack of follow up during sleeping time and parental beliefs that children are becoming older, the same authors argued that some children are usually sleeping in separate bedrooms from their parents which cause less usage of Insecticides Treated Nets(18).

Another study revealed that ITNs used for protection against mosquito bites have proven to be practical, highly effective and cost –effective intervention against malaria. A decline in malaria I sub-Saharan Africa is attributed to malaria control measures, predominately to the use of ITNs, IRS which have been implemented in high scale(14).

CHAPTER THREE

3. MATERIALS AND METHODS

3.1 Study area

The study area will be Bagamoyo district. Bagamoyo district is one among six districts of the Coastal region (Pwani) of Tanzania. Bagamoyo district is situated 59 km north of Dar-es- salaam(19). It is bordered to the North by Tanga region, to the West by Morogoro region, to the East by Indian Ocean and to the South by Kibaha and Kinondoni districts. The district has a population of 311,740, women being 157,542 and men 154,198(20).

Bagamoyo district lies between longitudes of 38° to 90° and latitudes of 6° and 7° above the sea level. The district covers the area of 9,842km², where 855 km² is covered by water while the remaining land which is 8,987km² is covered by dry lands(20).

The district has two parliamentary constituencies that are Bagamoyo and Chalinze. Bagamoyo is divided into six administrative divisions and twenty-five wards. The following are the wards found in Bagamoyo district; Bago, Chalinze, Chasimba, Dunda, Kibindu, Kimoro, Kiwangwa, Kongo, Lugoba, Magomeni, Masuguru, Matibwa, Msata, Msinune, Mwavi, Yombo, Zinga, Mkange, Saadani, Matipwili, Miono, Madamazigara, Mandera, Kimange, Mbwewe(21).

The main economic activities in Bagamoyo district include small scale farming, artisanal fishing, livestock’s keeping, mariculture, salt production, trade, and tourism. Bagamoyo is the home to many ethnic groups, such as wakwere, wazaramo, wazigua, masai and waswahili.

In health services, the following are diseases present in Bagamoyo; malaria, ascariasis, tuberculosis, trichuriasis and filariasis just to name the few.

3.2 Study design

A descriptive cross-sectional study will be conducted at Bagamoyo district to determine the prevalence of asymptomatic malaria among of school age children.

3.3 Study population

The study population will be school age children from the age of 6 to 14 years from which blood sample by finger prick will be taken for examining malaria in asymptomatic school children by the use Random Diagnostic Test (RDT).

3.4 Sample size estimation

The sample size will be calculated from the below bio statistical formulae,

N=Z² P (1-P)

£²

Where,

N=total number of subject requested in sample

Z=standard normal deviation value that correspond to a level of statistical significance P≤ 0.05 which is 1.96.

P=estimate of proportion of malaria prevalence among school age children in Bagamoyo which is 14% (sumari, 2017)

£ = which is the marginal error (5%)

N= 1.96²× 0.14 (1-0.14)/0.05²

N= 185.0114

185.0114*1.5 (D.E)

277.5

Non response rate= n/10% *100=

10/100 × 277.5= 27.75

Total sample size will be 277.5 + 27.75 =305.3

The sample size for this study will be 305 school age children.

3.5 Sampling technique

The study will use a multistage sampling technique which will involve three stages to obtain a sample size required.

At first, list of wards will be selected using multistage randomly sampling procedure whereby a list of 25 wards will be obtained with the assistance of DEO, and then one ward among of 25 wards will be selected randomly.

Also, from the selected ward, a list of villages that are found within a selected ward will be obtained. Followed by selecting randomly two villages, finally 3 schools will be randomly selected within the two given villages.

With the help of the head teacher, randomly selection of schoolchildren will be done to select study participants with the year ranging from 6 to 14. In the end, all the recruited schoolchildren will be given an informed consent that will be signed by their parents/guardian.

3.6 Eligibility criteria

3.6.1. Inclusion criteria

The inclusion criteria will be:

School children aged 6 to 14 years.
Children must be attending school.
Parents must sign the informed consent form for the child to participate in this study.
They must agree to give blood sample.

3.6.2. Exclusion criteria

The exclusion criteria will be:

Sick children.

· Children whose parent refused to sign consent forms.

· Children who will disagree to give blood sample

3.7. Study variables

3.7.1. Independent variables

The independent variables will be;

Socio demographic characteristics such as age and sex.
Risk factors such as gender, use of insecticide treated nets and indoor residual spraying, use of repellants, and lack of screened windows.
Knowledge on causative agent, transmission, treatment, control and prevention of asymptomatic malaria.
Malaria prevention methods such as use of ITN, use of ACTs, IRS, use of screened windows and use of body repellants.

3.7.2. Dependent variables

The dependent variable will be prevalence of asymptomatic malaria.

3.8. Data collection technique and procedures

3.8.1. Structured interview using questionnaire

A questionnaire will be prepared for the school age children to assess risk factors associated with asymptomatic malaria, knowledge on asymptomatic malaria and methods used in malaria prevention. School children will be instructed how to fill the forms before distributing to them.

3.8.2. Data collection Procedures.

Laboratory investigation of asymptomatic malaria will be done by using mRDTs. All necessary materials will be gathered at the testing area which includes RDT kit (test cassette, buffer, and blood collecting device). Each school child will be explained what the test is for and the procedures. Then the cassette will be removed from the foil package and labeled with particular number (identification number) and time. All these procedures will be done while wearing gloves, the puncture site will be disinfected (the fourth finger of non-dominant hand) with alcohol swab. Along that, a gentle prick will be made toward the bull of the 4^th finger and wipe off the first drop of blood with a dry cotton(22).

Using the blood pipette, a required amount of blood will be collected then transferred the collected blood to the cassette and then the buffer will be added 3 to 4 drops and finally the cassette will be placed for 15mn minutes before interpretation of the results. The interpretation of the results will be done as follow:

· Negative-the presence of only control band indicates a negative result

Positive-the presence of both control and test band indicates the positive result
Invalid-if the test doesn’t show the control band even if there is the control band.

Then reporting will be as RDT negative or RDT Positive or RDT invalid. Followed by discarding the cotton wool, RDT cassette and gloves into the box for infection waste(22).

3.9. Data quality management.

3.9.1. Recruitment of research assistant.

One research assistant with interviewing skills and medical background will be recruited and oriented to the study.

3.9.2. Pre-testing of data collection.

Prior to commencing the study, the questionnaire will be pre-tested in one of the primary schools (Muhimbili primary school) to check if there is a need for any modification in terms of structuring or rephrasing the questions to avoid bias. The school that will be used for pretesting will not be part of the actual data collection. Pre-testing will be done in 10% of the sample size (30 children). Then amendments of the questionnaire will be done to improve where the questions seem not clear to school age-children.

3.10. Data processing and analysis.

Data will be double entered, cleared and stored in SPSS version 24. The data will be double entered to minimize possibility of errors during data entry. Descriptive statistics will be done to obtain the frequencies of variables of interest. Association between independent variables and dependent variables will be done using logistic regression at the significance level of 0.05

Knowledge will be analyzed using knowledge score scale. The score will be given to both correct and incorrect responses, a total of 23 questions will be prepared and will be given to schoolchildren to answer them after a good instruction, and the correct score will be given 1 and an incorrect score will be given 0. Then scores will be categorized to the low, moderate and high level of knowledge as follows;

· 28-23 points =High level of knowledge

· 8-17 points= Moderate level of knowledge

· 0-7 points= Low level of knowledge

Finally, all the responses will be added to find the mean score for all the recruited children.

3.11. Ethical considerations.

Before conducting the study, ethical consideration will be requested from Muhimbili University of Health and Allied Sciences Institutional Review Board then permission to conduct this study in Bagamoyo will be requested from the Regional Administration officer, then to District Administration officer and other permission will be requested from District Education Officer (DEO). Then the written consent forms will be distributed to each participant in order to be given to their parents or guardians and request them to read and sign if they allow their children to participate in this study. All selected children will be instructed to bring back the signed informed consent forms.

3.12. Study limitation and mitigation.

Poor participation which can be caused by some of the school age children refusing to answer the asked questions and this will be mitigated by explaining the advantages of the study to them.

Response bias also may occur in this study and will be mitigated by telling them to be truthful to all asked questions.

Also, recall bias can be the one of the limitations, which will be mitigated by repetitively asking the same question to the same schoolchild and by giving enough time to remember.

CHAPTER FOUR

4.0. BULDGET AND ITS JUSTIFICATION

4.1. Budget.

A total of TSH 1,002,650/= will be required to accomplish this study. This budget provides necessary costs required and justification of each cost element.

Table 1: Budget description for each activity

S/N	ACTIVITY	QUANTITY	UNITY COST	TOTAL COST
1	STATIONERY
	Computer and Internet			20,000
	Typing and printing			30,000
	Rim	1	10,000	10,000
	Pencil	3	500	1,500
	Pen	5	500	2,500
	SUB TOTAL			64,000
2	EQUIPMENT AND MATERIALS
	Boxes of alcohol swab	5	5,000	25,000
	Boxes of syringes	5	10,000	50,000
	Boxes of mRDTs	9	40,000	360,000
	Boxes of gloves	4	15,000	60,000
	SUB TOTAL			495,000
3	ALLOWANCES
	Meals	10	10,000	100,000
	Teachers allowances	2	25,000	50,000
	Transport	10	5,000	50,000
	SUB TOTAL			200,000
4	OTHERS
	Pencils for children	305	500	152,500
	SUB TOTAL			152,500
	CONTINGENCY	10%		91,150
	GRAND TOTAL 911,500

4.2. BUDGET JUSTIFICATION

A total amount of 64,000/=will be used for stationery which includes internet services at internet café, printing other materials including pens, pencils and rim papers for documentation of data. Also, a total of 495,000/= will be spent for equipment and materials which includes buying swabs, gloves and mRDTs. A total of TSH 50,000/= will be used as a transport fee that is to and fro for 10 days, TSH 100000/= will be used for meals and the rest 91,150 /= will be spent as contingency which will cover any costs that will be extend beyond the planned budget.

4.3 WORK PLAN

Table 2: The work plan showing activities and timeline for each activity

ACTIVITY	DEC 2020	JAN 2020	FEB 2020	MAR 2020	JUN 2020	JLY 2020	AUG 2020	SEP 2020
Selection of title
Proposal development
Proposal correction
Proposal submission
Data collection
Data processing
Data analysis
Report writing
Report submission

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19. Mbwambo JS, Ndelolia D, Madalla N, Mnembuka B, Lamtane H a., Mwandya a. W. Climate change impacts and adaptation among coastal and mangrove dependent communities: a case of Bagamoyo district. First Clim Chang Impacts, Mitig Adapt Program Sci Conf. 2012;

20. National Bureau of Statistics. 2012 Population and housing census; Population Distribution by Adminstrative Areas. National Bureau of Statistics. 2013.

21. NBS. The United republic of Tanzania. National Beaural of Statistics: 2012 Population and Housing Census Population Distribution by Administrative areas. National Bureau of Statistics ministry of finance. 2013.

22. Ogboi JS, Agu PU, Fagbamigbe AF, Audu O, Akubue A, Obianwu I. Misdiagnosis of malaria using wrong buffer substitutes for rapid diagnostic tests in poor resource setting in Enugu , southeast Nigeria. Malar World J. 2014;

APPENDICES

Appendix 1: concert form English version

MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES

DIRECTORATE OF RESEARCH AND PUBLICATION

INFORMED CONSENT FORM

ID-NO

Consent to participate in the research study

Greetings! My name is Mkapa John from MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES (MUHAS), BMLS candidate. I am conducting a research project with the aim to determine prevalence and risk factors of asymptomatic malaria among of school children in Bagamoyo.

Study purpose

The study is aimed to determine the prevalence of asymptomatic malaria among of school age children, collecting information on the risk factors associated with asymptomatic malaria among of school age children, level of knowledge of school age children on malaria and determining the portion of students using malaria prevention methods.

What participation involves

The study will involve school age children ranging from 6 to 14 years who will be required to answer questions during interview and to provide finger prick blood sample for malaria.

Confidentiality

All collected information will be entered into computer with only study identification number without involving their names and unauthorized person will have no access to the data collected.

Benefits

If you agree your child to participate in this study, he /she will benefit directly or indirectly. Directly, any child who will found with malaria will be referred to the nearest health facility for management. Indirectly, the information she/he will provide will help to understand the knowledge of children on malaria controls and level of asymptomatic malaria among of school children in Bagamoyo. These findings will help the policymakers to address the problem.

Potential risks

I assure you that no any harm will be expected to happen to your child because of participation in this study however during finger prick one may feel some pain.

Right to withdraw and alternatives

Participation in this study is completely your choice. You can stop your child participation in this study at any time even if you have already given your consent. Refusal to participant or withdraw from the study will not involve any penalty.

Contacts.

If you ever have questions about this study. You may contact the following address.

MUHAS

Head, Department of Parasitology and Medical Entomology

P.O.BOX 65001

School of Medicine.

If you have understood and ready to participate, please give the sign below.

Signatures:

1. Participant ……………......

2. Researcher………………...

Appendix II: Consent form Swahili version

CHUO KIKUU CHA AFYA NA SAYANSI SHIRIKISHI MUHIMBILI

KURUGENZI YA UTAFITI NA UCHAPISHAJI MUHIMBILI

FOMU YA RIDHAA

NAMBA YA UTAMBULISHO..................

Ridhaa ya kushiriki katika utafiti

Salamu! Jina langu ni Mkapa John kutoka CHUO KIKUU CHA AFYA NA SAYANSI SHIRIKISHI MUHIMBILI (MUHAS), Mwanafunzi wa shahada ya kwanza ya sayansi ya maabara za binadamu. Ninafanya utafiti kwa madhumuni ya kuchunguza” Sababu zinazopelekea kiwango cha maambukizi ya malaria isiyo onyesha dalili za ugonjwa kwa watoto wa shule ya msingi wilayani Bagamoyo ''Tanzania.

Kusudi la utafiti

Utafiti huu unakusudiwa kufahamu kiwango cha maambukizi ya malaria isiyoonyesha dalili kwa watoto wa shule ya msingi, kukusanya taarifa juu ya sababu zinazopelekea kuongezeka kwa malaria isiyo onyesha dalili za ugonjwa kati ya watoto wa umri wa shule ya msingi, kiwango cha maarifa ya watoto wa umri wa shule ya msingi juu ya ugonjwa wa malaria na kuweza kufahamu sehemu ya wanafunzi wanaotumia njia za kuzuia malaria.

Ushiriki utahusisha nini

Utafiti huo utahusisha watoto wa umri wa kwenda shule kuanzia miaka 6 hadi 14 ambao watalazimika kujibu maswali katika dodoso na kutoa sampuli ya damu ya kidole kwa ugonjwa wa malaria.

Usiri

Taarifa yoyote iliyokusanywa itaingizwa kwenye kinakilishi na nambari ya kitambulisho cha kusoma tu bila kuwashirikisha majina yao na mtu ambaye hajatambuliwa hataweza kupata tarifa iliyokusanywa.

Faida za kushiriki katika utafiti huo

Ikiwa unakubali mtoto wako kushiriki katika utafiti huu, atafaidika moja kwa moja au zisizo moja kwa moja. Moja kwa moja, mtoto yeyote atakayepatikana na ugonjwa wa malaria atapelekwa kwenye kituo cha afya cha karibu na shule kwa usimamizi. Zisizo Moja kwa moja, tarifa zitakazopatikana ziitasaidia kuelewa ufahamu wa watoto juu ya udhibiti wa ugonjwa wa malaria na kiwango cha ugonjwa huu miongoni mwa watoto wa shule ya msingi wilayani Bagamoyo. Matokeo haya yatasaidia watunga sera kushughulikia tatizo hili.

Hatari zinazowezekana kutokea

Nakuhakikishia kwamba hakuna madhara yoyote yanayotarajiwa kutokea kwa mtoto wako kwa sababu ya kushiriki katika utafiti huu, pengine anaweza kuhisi maumivu kidogo tu kutokana na kuchoma kidole cha mkononi wakati wa kutoa damu.

Haki ya kujiondoa na mbadala

Ushiriki katika utafiti huu ni hiari yako kabisa. Unaweza kusimamisha Ushiriki wa mtoto wako kwenye utafiti huu wakati wowote hata ikiwa umeshampa idhini yako. Kukataa kuhusika au kujiondoa kwenye utafiti hautahusisha adhabu yoyote.

Anwani

Ikiwa utakuwa na maswali juu ya utafiti huu. Unaweza kuwasiliana na anwani ifuatayo.

MUHAS

Mkuu wa Idara ya vimelea na matibabu

P.O.BOX 65001

Shule ya Tiba.

Ikiwa umeelewa na tayari kumuruhusu mtoto wako kushiriki, tafadhali Saini hapa chini.

Saini:

1. Mshiriki ……………......

2. Mtafiti ………………….

Appendix III: Questionnaire English Version

Questionnaire No.......................

PREVALENCE AND RISK FACTORS FOR ASYMPTOMATIC MALARIA AMONG SCHOOL CHILDREN IN BAGAMOYO DISTRICT, TANZANIA.

Name of the ward………

Name of the village……...

Name of the school……….

Identification number of the interviewee…………………….

PART A: Demographic Data

1. Sex

1. Male

2. Female [ ]

2. What is your age in years...................?

3. Which class are you………………….?

PART B: Risk factors for asymptomatic malaria

1. Do you sleep under ITNs?

a. Yes [ }

b. No (if no go to number 2)

2. What are reasons for not using ITNs at home?

a. ITNs are not effective in preventing malaria

b. Used for other purpose (mention the purpose)

c. Weather

d. Not available

e. Others (mention) …………… [ ]

3. What is the structure of your sleeping room?

a. No space for hanging nets

b. The room is open

c. There is enough space in the room

d. Nets are not easily available

e. Others (mention the structures) ……………………….

4. What do you think are the advantages of children sleeping in the nets?

a. Reduce the burden of malaria on them

b. Children sleep better

c. Just for luxuriously

d. When I sleep under net. Nothing bothers me.

e. Others (mention)………………………….

[ ]

Do you use IRS at your home? If no go to question 6

a. Yes

b. No

6. What is the reason of not using IRS at your home?

a. IRS has bad smell

b. We use ITNs hence no reason of using IRS

c. Not easily available

d. Our windows have wire mesh

e. Others (mention)…………………………….

[ ]

7. What is the structure of your home?

a. The room has Screened window

b. Open windowed

c. The door is open at night

d. Windows have wire meshes [ ]

e. Others (mention)…………………….

8. How many ITNs do you have in the household?

a. Two

b. Five

c. More than five

d. None

e. Mention (others)……………………..

9. Are you using insecticide treated nets? If Yes go to question 10.

a. Yes

b. No

c. I don’t know

10. How did you get your ITNs at home?

a. Parents brought

b. Free from the government

c. Voucher system

d. I don’t know

e. Hospital

f. Others (mention)……………………………………..

11. Which of the following are the methods to prevent malaria infections apart from insecticide treated nets

a. IRS

b. Cleaning around home

c. Never taught

d. Insuring widows have wire mashes

e. Closing windows

f. Others (mention)……………………….

PART C: KNOWLEDGE ON MALARIA

1. Have you ever heard of malaria (If yes go to question 2)

a. yes

b. no

2. Where did you get information about malaria?

a. Media

b. Health facility [ ]

c. School

d. Home

e. Others (mention)

3. What is the causative agent of malaria.......?

Pasmodium parasites
Mosquitoes
Chicken [ ]
Worms
Fleas

4. How is malaria transmitted..............?

Through inhalation
Through Biting by mosquitoes [ ]
Through Drinking contaminated water
Through Eating without washing hands

others (mention)

5. What are the common symptoms for malaria.........? circle all the possible answers

a. General body weakness [ ]

b. Feeling well

c. Joint strongest

d. Ability to eat

e. Sweating

f. fever

g. Others (mention)…………………………..

6. How can you treat malaria? Circle all the possible answers

a. Going to hospital

b. Going to traditional healer

c. Drinking water regularly

d. Eating balanced diet

e. Using ACTs

f. Others (mention)………...

7 What are the methods which can be used to control and prevent malaria? Circle all the possible answers

Sleeping under ITNs
Sleeping while watching TV
Not sleeping the whole night [ ]
Going to school daily
Closing doors and window at night
Using IRS
Others (mention)

8. When you get malaria episode, what precaution do you normally use first?

Taking ACTs
Informing parents [ ]
Giving information to teachers
Sleeping continuously under nets
Others

9. Which age group is at a higher risk of acquiring malaria?

a. People of any age

b. Under-five children [ ]

c. Only elders

d. Only primary school children

e. People of any age group

10. Where should children with malaria seek treatment?

a. In the community

b. Through traditional healers

c. During clinical medicine

d. They should ask their parents

e. Children should ask their teachers

f. Others [ mention ]……………………

11. What is the single most important practice to reduce malaria infections?

a. Hand washing

b. Cleaning environment around home

c. Eating balance diet

d. Sleeping with mother

e. Use of ITNS

f. Others (mention) ……………. [ ]

12. What are the behaviors associated when using bed net when sleeping at night which can cause you to be bitten by mosquitoes ?

a. Bed sharing

b. Bed net not compliant

c. Sleeping patterns like limb hanging outside of the net

d. We sleep well enveloped by bed net

e. Mention (others) [ ]

Appendix IV: Questionnaire Swahili version

DODOSO Namba ya dodoso ………………………

SABABU ZINAZOPELEKEA KIWANGO CHA MAAMBUKIZI YA MALARIA ISIYOONYESHA DALILI ZA UGONJWA KWA WATOTO WA SHULE YA MSINGI WILAYANI BAGAMOAYO.

SEHEMU A: Takwimu za kidemografia

1jinsia

a. Mwanaume

b. Mwanamke [ ]

3. Una umri gani……..?

4. Uko darasa la ngap……….i?

SEHEMU B:

Sababu za hatari za ugonjwa wa malaria isiyo onyesha dalili.

1. Je, unalala ndani ya chandarua? kama ni hapana nenda namba 2

a. Ndiyo

b. .Hapana

2 Sababu zipi zinakufanya usitumie chandarua chenye dawa

a. Chandarua chenye dawa siyo njia halisi ya kuzuia malaria

b. Zinatumika kwa matumizi mengine *(Taja………….)

c. Hali ya hewa

d. Zingine ,(taja)……………………

3. Je, hali ya chumba unacholala ikoje?

a. Hakuna nafasi ya kuweka chandarua

b. Chumba kina uwazi mzuri

c.Chumba kina nafasi ya kutosha

d. Chandarua hakipatikani kwa urahisi

e.Vingine (taja)……………………………….

4. Je unafikiri ni faida zipi za kutumia chandarua

a. Kupunguza maambukizi ya malaria

b. Watoto hulala vizuri ndani ya chandarua

c. Kwa ajili ya raha tu

d. Nikilala kwenye chandarua sipati shida yoyote

e. Menginyo taja…….

5. Je mnatumia dawa ya kupulizia kuua mbu

a. Ndiyo

b. Hapana, kama hapana nenda swali namba

6. Zipi sababu zinawafanya msitumie dawa ya kupulizia kuua mbu?

a. Dawa ya kupulizia ina harufu mbaya

b. Tunatumia chandarua, hivyo hakuna umuhimu kutumia dawa ya kupulizia kuua mbu

c. Dawa hizi hazipatikani kirahisi

d. Madirisha yetu yana nyavu hivyo hazipitishi mbu

e. Zingine (taja)

7. Upi ni mwonekano wa nyumba yenu

a. Chumba kimefunikwa na mapazia

b. Madirisha yamefunguliwa

c. Milango ipo wazi wakati wa usiku.

d. Madirisha yamezungushiwa nyavu

e. mengineyo, taja……..

8. Je mna jumla ya vyandarua vingapi vyenye dawa nyumbani?

a. Viwili

b. Vitano

c.Zaidi ya vitano

d. Hatuna

e. Taja idadi nyingine……………………….

9. Je chandarua chako kina dawa?

a. Ndiyo

b. Hapana

c. Sijui

10. Je mlipataje hicho chandaraua?

a. Wazazi walinunua

b. Tuligawiwa bure na serikali

c. Sifahamu

d. Hospitalini

e. Pengine (taja)

11. Zipi ni njia zingine zinazofahamika kuzuia malaria unazozifahamu mbali n chandarua chenye dawa?

a. Njia ya kupulizia dawa

b. Kusafisha mazingira yanayotuzunguka

c. Sijawahi kufundishwa

d. Kufunga madirisha

e. Zingine ( taja)

SEHEMU C: UFAHAMU JUU YA MALARIA

1. Je unafahamu kuhusu uonjwa wa malaria

a. Ndiyo

b. Hapana. Kama ni ndiyo nenda swali la 2

2. Je! habari kuhusu ugonjwa wa malaria ulipata wapi?

a. Vyombo vya habari

b. Kituo cha afya [ ]

c. Shule

d. Nyumbani

e. Pengine ... (Taja)…………………….

3. Malaria husababishwa na nini?
a. Kidubini cha Plasmodium
b. Mbu

c. Kuku [ ]
d. minyoo

e. viroboto

4. .Malaria huambukizwa kwa njia zipi ???
a. Kuvuta pumuzi
b. Kuumwa na mbu [ ]
c. Kunywa maji machafu
d. Kula bila kunawa mikono

5. Zipi ni dalili za ugonjwa wa malaria?

a. Maumivu ya mwili mzima

b. Kujiskia vizuri

c. Uimara wa viungo

d. Uwezo wa kula

e. Mwili kupata jasho

f. Zingine ..

6. Je ni zipi kati ya njia zifuatazo hutumika kama tiba juu ya maambukizi ya malaria? Zungushia majibu yote ambayo ni sahihi

a. kwenda hospitalini

b. kwenda kwa wagnga wa kienyeji

c. kunywa maji mara kwa mara

d. .kula chakula chenye mlo kamili

e. matumizi ya dawa mseto

f. .mengineyo

7. Njia ifuatayo inayotumiwa kudhibiti na kuzuia ugonjwa wa malaria? Zungushia majibu yote ambayo ni sahihi

a. Kulala ndani ya chandarua chenye dawa

b. Kulala ukitazama TV

c. Usilale usiku kucha [ ]

d. Kuenda shuleni kila siku

e. Kufunga milango na madirisha wakatia wa usiku

f. Zingine ( taja)

8. Je, ni kipi cha kwanza kunafanya kama matibabu unapougua malaria

a. Natumia dawa mseto

b. Natoa taarifa kwa wazazi [ ]

c. Nawapa tarifa walimu

d. Nalala mara kwa mara

e. Kingine....

9. Ni watu wa umri gani wapo kwenye hatari ya kuambukizwa na ugonjwa wa Malaria?

a. Watu wa umri wowote

b. Watoto wenye umri chini ya miaka mitano [ ]

c. Wazee

d. Watoto wa shule ya msingi tu

e. Umri wowote

10. Wapi utapata tiba ukiugua malaria?

a. Katika jamii

b. Kwa waganga wa kienyeji

c. Kwa watalaamu wa afya

d. Wawaulize Wazazi wao

e. Wawaulize walimu

f. PenginePO (Taja)…….

11. Ipi ni njia bora ya kujikinga na malaria

Kunawa mikono
Kusafisha mazingira ya nyumbani
Kuchelewa Kulala

Kulala na mama
Taja zingine…….

12. Zipi ni tabia hujitokeza pindi unapo lala kwenye chandarua wakati wa usiku ambazo zinaweza sababisha kuumwa na mbu?

a. Kuchangia kitanda

b. Chandarua kukosa ubora mfano uchafu

c. Kulala miguu nje ya chandarua

d. Tunalala vizuri ndani ya chandarua

Zingine .....

DATA SHEET

Table 3: Data sheet

S/NO	PARTICIPANTS	AGE	SEX	mRDTs RESULTS

PREVALENCE AND RISK FACTORS OF ASYMPTOMATIC MALARIA AMONG SCHOOL CHILDREN IN BAGAMOYO DISTRICT

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