End of Project Evaluation of the School Health Malaria Control Initiative (SMHCI)

Abstract

Malaria is the world’s most important parasitic infection, ranking among the major health and developmental challenges for the poor countries of the world [1]. Recent global indices show that in 2002, 2.2 billion people were exposed to the threat of Plasmodium falciparum malaria, resulting to an estimate of 515 (range 300–660) million clinical attacks attributable to this parasite during that year [2]. A description of spatial analysis of populations at risk of P. falciparum, indicate that 2.37 billion people are at risk of P.falciparum transmission worldwide with 26% in the African region. Globally, 42% of the population exposed with P. falciparum were classified as inhabiting areas of unstable transmission [3]. All four species of human Plasmodium occur in Kenya: P. falciparum, P. malariae, P. ovale and P. vivax. P. falciparum, which causes the severest form of the disease, accounts for 98 % of all malaria infections. The major malaria vectors in Kenya are members of the Anopheles gambiae complex and An. Funestus [4]. The epidemiological patterns in Kenya are largely determined by altitude, rainfall patterns and temperature. This creates four main malaria epidemiological zones. First are the endemic areas which have stable malaria with altitudes ranging from 0 to 1,300 meters around Lake Victoria in western Kenya and the coastal area. The vector life cycle is usually short and survival rates are high because of the suitable climatic conditions. Transmission is intense throughout the year, with annual entomological inoculation rates of 30–100. The second zone are the seasonal transmission areas mostly in arid and semi-arid areas of northern and southeastern parts of the country which experience short periods of intense malaria transmission during the rainfall seasons. The third zone 11 is the epidemic prone area of western highlands of Kenya. Malaria transmission is seasonal, with considerable year-to-year variation. Epidemics are experienced when climatic conditions favor sustainability of minimum temperatures of around 18oC. This increase in minimum temperatures during the long rains favors and sustains vector breeding, resulting in increased intensity of malaria transmission. The whole population is vulnerable and case fatality rates during an epidemic can be up to ten times greater than those experienced in regions where malaria occurs regularly. The fourth zone is the low risk malaria areas which covers the central highlands of Kenya including Nairobi. The temperatures are usually too low to allow completion of the sporogonic cycle of the malaria parasite in the vector. However, the increasing temperatures and changes in the hydrological cycle associated with climate change are likely to increase the areas suitable for malaria vector breeding introducing malaria transmission in areas where it had not existed before[4]. In terms of malaria burden, each year, it is estimated that 20 million Kenyans are regularly infected by P. falciparum with children being the most affected of whom an estimated 26,000 die from the direct consequences of malaria infection[5]. The current estimates indicate that clinically diagnosed malaria is responsible for 30 per cent of outpatient consultations, 15 per cent of hospital admissions and 3–5 per cent of inpatient deaths. In 2007 for example, based on health management information system data, there were 9.2 million reported clinically diagnosed malaria cases in the public health sector. Inpatient data show that malaria is responsible for about one-fifth of admissions nationally [4]. In terms of case management, Kenya adopted the artemisinin-based combination treatment (ACT) artemether lumefantrine (AL) as the first-line treatment for uncomplicated malaria following the precipitous decline in the efficacy of sulphadoxine pyrmethamine (SP) in 2004 [6]. AL was rolled out in 2006 with efficacy at baseline being 96 % which remained the same in 2008 [4]. In Kenya, the national malaria control programme is operationalised by the Division of Malaria Control (DoMC). The DoMC has the overall responsibility for planning and coordination of inputs and activities for malaria control at all levels. DoMC activities are guided by the Kenya National Malaria Strategy (KNMS). The recently launched current eight year KNMS spells out six specific objectives with operational targets within specified periods. Two of these objectives support interventions that focus on school malaria prevention initiatives. In particular, objective one aims to have at least 80 % of people living in malaria risk areas using appropriate malaria prevention interventions by 2013. One of the activities within this objective is to support malaria-free schools initiative through a package of interventions that includes distribution of Long Lasting Insecticide Treated Nets (LLITN), mainstreaming malaria control in the school curriculum and implementation of indoor Residual Spraying (IRS) in schools. Focus in schools is also mentioned in the fourth objective that aims to strengthen surveillance, monitoring and evaluation systems so that key malaria indicators are routinely monitored and evaluated in all malaria endemic districts by 2011. The approach aims to strengthen facility and school-based malaria surveillance with a sentinel school-based monitoring of parasite 12 prevalence being undertaken on annual basis. Embedded within the KNMS is the recognition of the role of Information Education and Communication (IEC) activities to enhance malaria control activities. Among the key partners identified to support the IEC strategy is the ministry of education (MoE) which oversees schools and develops curriculum for the education sector.