EPIDEMIOLOGY OF MALARIA AMONG PREGNANT WOMEN ATTENDING

THE ZONAL HOSPITAL BORI, KHANA LGA, RIVERS STATE

BY

OGBU, JASON CHETA

DE; 2013/2993

A RESEARCH PROJECT SUBMITTED TO

THE DEPARTMENT OF MEDICAL LABORATORY SCIENCE,

(MEDICAL MICROBIOLOGY OPTION), FACULTY OF SCIENCE,

RIVERS STATE UNIVERSITY OF SCIENCE AND TECHNOLOGY,

NKPOLU-OROWORUKWO, PORT HARCOURT, RIVERS STATE.

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

AWARD OF BACHELOR OF MEDICAL LABORATORY SCIENCE (B.MLS)

JULY,2016
 DECLARATION

I, OGBU JASON CHETA with matriculation number DE:2013/2993. Hereby declare

that this project is a product of original ideas under the supervision of Dr(Mrs) G.N. Wokem

and has not been submitted either in part or in full to this university for the award of any

degree.

------------------------------- ------------------------

OGBU JASON CHETA DATE

(DE:2013/2993)
 CERTIFICATION
This is to certify that this project work was carried out by OGBU, JASON CHETA. With

Matriculation Number DE: 2013/2993 in the Department of Medical Laboratory Science

(Medical Microbiology Option), Faculty of Science, Rivers State University of Science and

Technology, Port-Harcourt in partial fulfilment of the requirement for the Award of

Bachelor of Medical Laboratory Science (B.MLS) Degree.

DR.(MRS) G.N. WOKEM ------------------------ ----------------

(Project supervisor) Signature Date

DR.(MRS) G. N. WOKEM ------------------------ --------------

(Head of Dept. Med. Lab. Sc.) Signature Date

PROF. V. B. PEPPLE ------------------------ --------------

(Dean Faculty of Science) Signature Date

------------------------------ ------------------------ --------------

(External Examiner) Signature Date
 DEDICATION
This project work is dedicated to God Almighty who through his mercy and grace made this

works a reality.

To my father, C.A. Ogbu, my mother ,Mrs. Edna Ogbu and brother Mr Patrick Ogbu for

their esteemed support both emotionally and financially.

 ACKNOWLEDGEMENT
Firstly, I am grateful to God Almighty for the grace, strength, protection, knowledge and
wisdom granted to me throughout the entire period of this programme and also for the
strength required to overcome the challenges.

My profound gratitude goes to my project supervisor, DR(MRS) G.N.WOKEM for her

motherly care and calls she puts through to enquire how far I have gone in the project, I say
thank you Ma.

I also appreciate my colleagues who assisted and encouraged me despite any challenge
during the course of this project and other academic activities, persons like Edheba Nelson,
Pascal Ezeagu, Awajiowa Ebirien, DumneBari, Obilor chizoba, and all medical laboratory
science students.
 LIST OF TABLES

Table 1: Age distribution of malaria parasite in pregnant women of those positive and
negative to malaria.

Table 2: Distribution of malaria in pregnant women based on the use of Insecticide Treated
Nets(ITN).

Table 3: Distribution of malaria among pregnant women based on gestational period.

Table 4: Prevalence of malaria among pregnant women based on drug used.

Table 5 Gravidity distribution of malaria among pregnant women.

Table 6: CHI- square table of positive and negative cases of malaria among pregnant women
using age distribution.
 LIST OF FIGURES

Fig. 2.1: Life cycle of Plasmodium species

Fig. 4.1: Bar chart showing age distribution of malaria parasitaemia in pregnant women

Fig. 4.2: Bar chart showing distribution of pregnant women that make use of Insecticide
Treated Nets and those that dont

Fig. 4.3: Bar chart showing distribution of malaria parasitaemia among pregnant women
based on gestational period

Fig. 4.4: Bar chart showing distribution of malaria parasitaemia among pregnant women
based on drug used

Fig. 4.5: Bar chart showing distribution of malaria parasitaemia among pregnant women
based on gravidity
 ABSTRACT

Malaria during the period of pregnancy continues to be a major health problem in endemic countries with
clinical consequences including death of both mother and child. In Nigeria, statistics shows that as many as
300,000 lives especially those of children and pregnant women are lost annually to malaria. This study was
aimed at assessing the epidemiology of malaria among pregnant women living in Bori, Khana Local Council, a
suburb of Rivers State, Nigeria. 200 pregnant women attending the antenatal clinic at Zonal Hospital Bori in
Khana Local Government Area of Rivers State were recruited for this study. This study was carried out from
April 2016 to June 2016. The result showed that malaria infection was prevalent during pregnancy. A total of
148 (74%) of the pregnant women were positive to and showed symptoms of malaria while 52 (26%) were
negative and showed no symptoms of malaria. The positive cases of all age groups showed to be statistically
significant from the negative cases at P<0.05 All positive cases were caused by Plasmodium falciparum.
Parasitaemia was highest in women aged 31-35 with percentage prevalence of 34%. Falciparum malaria
prevalence decreased with increasing gravidity and was highest in the primigravidae (48.5%) while
multigravidae having 25.5%. Highest falciparum malaria parasitaemia was recorded in second trimester (40.5%)
of pregnancy. Pregnant women that used insecticide treated nets and took malariacidal drugs had the lowest
prevalence of parasitaemia of 34% and 12% respectively.
 TABLE OF CONTENT

Title page.i

Declaration.ii

Certificationiii

Dedication..iv

Acknowledgmentv

List of tables..vi

List of figuresvii

Abstractviii

Table of content ix-x

CHAPTER 1: INTRODUCTION.1

1.1 Objective of the study 3

CHAPTER 2: LITERATURE REVIEW..4

2.1 Background of malaria .4

2.2 Malaria in pregnancy 5
2.3 Lifecycle of malaria parasite 7
2.4 Epidemiology of malaria.10
2.5 Diagnosis of malaria 11
2.6 Clinical features of Plasmodium species. 12
2.6.1 Plasmodium falciparum.12
2.6.2 Plasmodium vivax.13
2.6.3 Plasmodium malariae....13
2.6.4 Plasmodium ovale.14
2.7 Management of malaria14
2.7.1 Chemotherapeutic control.14
2.7.2 Biological control..15
CHAPTER 3 : MATERIALS AND METHODS16

3.1 Study Area.16

3.2 Study population.17
3.3 Ethical consideration..17
3.4 Sample collection17
3.5 Blood film preparation18
3.5.1 Thin blood film.18
3.5.2 Thick blood film.. .18
3.6 Staining procedure for thick blood film..18
3.7 Staining procedure for thin blood film...18
3.8 Microscopic examination19
3.9 Data analysis19

CHAPTER 4 : RESULTS..20

CHAPTER 5 : . .31
5.1 DISCUSSION.31
5.2 CONCLUSION...32
5.3 RECOMMENDATIONS.. 33

REFERENCES...34

APPENDIX39
 CHAPTER 1

INTRODUCTION

Malaria is an infection that is caused by the parasite belonging to the kingdom Protista,

phylum Apicomplexa, class Aconoidasida, order Haemosporidia, family Plasmodiidae and

genus Plasmodium (Ricci,2012). There are four species of the Plasmodium, normally

infecting man. These are Plasmodium ovale, Plasmodium falciparum, Plasmodium vivax and

Plasmodium malariae (Enato et al., 2009). In Nigeria, 99.9 percent of all cases of malaria is

due to Plasmodium falciparum (WHO, 2015). This is the species that is responsible for the

severe form of this disease that leads to death.

Malaria is a wide-ranging infection in the tropics and subtropics, an estimated 3.3 billion

people are at risk of malaria, of whom 1.2 billion are at high risk. In high-risk areas, more

than one malaria case occurs per 1000 population (WHO, 2014). Nigeria is known for high

prevalence of malaria and it is a leading cause of morbidity and mortality in the country

(WHO, 2015). Records have shown that at least 60 percent of the Nigeria population suffers

from at least one episode of malaria each year.

Malaria is classified into either "severe" or "uncomplicated" by the World Health

Organization (Nadjm and Behrens, 2012). It is deemed severe when any of the following

criteria are present, otherwise it is considered uncomplicated (WHO, 2014).

The presence of decreased consciousness, Significant weakness such that the person is unable

to walk, inability to feed, two or more convulsions, low blood pressure (less than 70 mmHg in

adults and 50 mmHg in children),Breathing problems, circulatory shock, Kidney failure or

haemoglobin in the urine, bleeding problems, or haemoglobin less than 50 g/L (5 g/dL)

Pulmonary oedema, blood glucose less than 2.2 mmol/L or 40 mg/dL (Ricci, 2012).
Malaria is transmitted from the bite of an infected female Anopheles mosquito to man. The

mosquito bite introduces the parasites from the mosquito's saliva into a person's blood (WHO,

2014). Anopheles belongs to the phylum Arthropoda, class Insecta, order Diptera, family

Culicidae, genus Anopheles (Walker, 2002). Out of 484 recognised species, over 100 can

transmit human malaria, but only 3040 commonly transmit parasites of the genus

Plasmodium that cause malaria, which affects humans in endemic areas (Walker, 2002).

Anopheles gambiae is one of the best known species, because of its predominant role in the

transmission of the deadly species Plasmodium falciparum (Chukwuocha, 2010) .

Malaria during pregnancy has serious consequences to the mother, her foetus and the neonate

and it is a serious health challenge. The protection of pregnant women living in malaria-

endemic countries like Nigeria has been of particular interest to many National Malaria

Control Programmes because of their reduced immunity (Anorlu et al., 2001). The reduced

immunity makes her more susceptible to infection than non-pregnant women and increasing

the risk of severe anaemia and death (Adefisoye et al., 2007).

The evidence of malaria infection can be obtained from the density of peripheral parasitaemia

during pregnancy at various trimesters. Age has also been implicated as epidemiological

studies have shown that malaria in pregnancy is more prevalent in younger than older age

groups (Nwangha et al., 2009). In the endemic countries of Africa, pregnant women bear the

brunt of the burden of malaria disease, this is because they have lower immunity to the

disease compared to other people in the same environment (Raimi et al., 2010).

Maternal mortality is twice in pregnant malaria women than among non-pregnant patients

with severe malaria (Enato et al., 2009). Anaemia is the most common symptom of malaria in

pregnancy and usually develops during the second trimester (Uneke, 2008). Cerebral malaria

is rare in adults except during pregnancy and is responsible for many maternal malaria deaths

(McGregor,2004). Severe falciparum malaria may cause deformities in the genital tract to
make conception impossible or if conception does occur it may prevent normal implantation

and development of the placenta (Uko et al.,1998).

Although so much work have been published on the epidemiological survey of malaria in

major cities of Nigeria but little information is available about the epidemiology of this

disease in the suburbs or outskirts of major cities like Bori, Rivers State. Bori was chosen

because of its topography ,rainfall, poor drainage system and waste disposal system, the

attitude of residents disposing waste into the little available gutters around the metropolis and

high human-vector contact in the area.

1.1 OBJECTIVES OF THE STUDY

The specific objectives of the study are:

To identify the aetiology of the infection.

To determine the distribution of the disease based on different criteria among pregnant

women attending antenatal in the Zonal hospital, Bori, Rivers State.

To evaluate factors influencing the infection in the study area.

 CHAPTER 2

LITERATURE REVIEW

2.1 Background of Malaria

The term malaria originates from Medieval Italian word: mala aria"bad air"; the disease

was formerly called ague or marsh fever due to its association with swamps and marshland

(Reiter, 1999). The term first appeared in the English literature about 1829 (Webb,2009).

Malaria was once common in most of Europe and North America where it is no longer

endemic, though imported cases do occur (Webb, 2009).

Scientific studies on malaria made their first significant advance in 1880, when Charles

Laverana French army doctor working in the military hospital of Constantine in Algeria

observed parasites inside the red blood cells of infected people for the first time. He therefore

proposed that malaria is caused by this organism, the first time a protist was identified as

causing disease (Webb,2009). For this and later discoveries, he was awarded the 1907 Nobel

Prize for Physiology or Medicine. In 1908, Carlos Finlay, a Cuban doctor treating people

with yellow fever in Havana, provided strong evidence that mosquitoes were transmitting

disease to and from humans (Tan and Sung, 1998).

Malaria is a life threatening parasitic disease transmitted by the female Anopheles sp

mosquitoes. Malaria is the most highly prevalent tropical disease, with high morbidity and

mortality and high economic and social impact (WHO, 2014).

2.2 Malaria in pregnancy

Women are not specifically more susceptible to malaria (Achidi et al., 2005). However,

Pregnancy increases the susceptibility to malaria due to lack of immunity against malaria and

thereby increase in morbidity and mortality (Adefisoye et al., 2007). This is possibly due to

transient immunological suppression needed to allow the development of a foreign allograft.

Pregnancy is known to increase the susceptibility to bacterial, parasitic and viral, especially

HIV infections (Stekettee, 2001). There are several studies on malaria during pregnancy and

the effect of malaria on foetus available. All these works give information either on

epidemiology of malaria during pregnancy based on parasitological observations or on

complications (anaemia, low birth weight, foetal and perinatal mortality, maternal mortality,

congenital malaria and general complications of puerperal sepsis, postpartum haemorrhage

(Raimi et al., 2004). The studies focused on P.falciparum infection. Recently, the role of

P.vivax during pregnancy has been also described ( Anorlu et al., 2001).

Malaria infection during pregnancy is a major public health problem in tropical and

subtropical regions throughout the world (Ofori et al., 2009). Malaria during pregnancy has

been most widely evaluated in Africa mainly in South of the Sahara where 90% of the global

malaria pregnant burden occurs. The burden of malaria infection during pregnancy is caused

mainly by Plasmodium falciparum, They were the most common malaria species in Africa

(Adefisoye et al., 2007). Globally pregnant women in malarious areas may experience a

variety of adverse consequences from malaria infection including maternal anaemia,

placental accumulation of parasites, low birth weight (LBW) from prematurity and

intrauterine growth retardation (IUGR), foetal parasite exposure and congenital infection, and

infant mortality (Steeketee et al.,2001).

In the World Malaria Report 2012, Nigeria accounted for a quarter of all malaria cases in the

45 countries endemic for malaria in Africa. In Nigeria, 11% of maternal deaths are attributed

to malaria (WHO,2014). Malaria in pregnancy remains an obstetric, social and medical

problem requiring multidisciplinary, multidimensional solutions (WHO, 2014). In Kenya and

Nigeria malaria accounted for 20% to 30% of Infant mortality in 1970 to 1975. Saeed and

Ahmed(2003) in a study of displaced people and Refugees in Sudan found that the major

cause of death was malaria. This may be attributed to the fact that refugees live in poor

shelter and generally their socio-economic status is low. The same authors found that malaria

contributed 15.9% of total deaths. Abstracts on malaria mortality state that malaria

contributes 10 000 maternal deaths per year, 5-14% low birth weight and 3.8% infant deaths

per year (WHO, 2010). The parasite prevalence is higher in poor families with pregnant

women or children who have little protection against mosquitoes and have no money to pay

for transportation to health centres (WHO, 2010)

In a study by Raimi and Kanu(2010), Pregnant women within the age group of 20 to 30 years

had the highest number of parasite density while those above 40 years had the least.

Primigravidae were found to be susceptible more to malaria with parasite density of 2112.50

420.90 parasites/ml. Women in their second trimester of pregnancy were found to have the

highest parasite load.

Khan et al.,(2006) in their work supported the existing knowledge that high prevalence of

malaria parasite at lower ages and low prevalence at higher ages is due to the existence of

natural immunity to infectious disease including malaria. However, Lander et al.,(2002)

reported no significant association between malaria infection and maternal age.

An analysis of malaria in pregnancy in Africa revealed that parasiteamia is significantly

common and heavier in primigravidae than multigravidae (Achidi, 2005).

2.3 Life cycle of malaria parasite

The life cycle of malaria is passed in two hosts and has sexual and asexual stage.

Vertebrate host - man (intermediate host), where the asexual cycle takes place. The parasite

multiplies by schizogony and there is formation of male and female gametocytes.

Invertebrate host - mosquito (definitive host) where the sexual cycle takes place. The union

of male and female gametes ends in the formation of sporozoites (Uko et al., 1998).

The life cycle passes in four stages:

Three in man:- Pre - erythrocytic schizogony, erythrocytic schizogony, exo- erythrocytic

schizogony, One in mosquito Sporogony. (Snow et al., 2005).

Introduction into humans - when an infective female Anopheles mosquito bites man, it

inoculates saliva containing sporozoites (infective stage). Pre- Erythrocytic schizogony

sporozoites reach the blood stream and within 30 minutes enter the parenchymal cells of the

liver, initiating a cycle of schizogony. Multiplication occurs in tissue schizonts, to form

thousands of tiny merozoites. Merozoites are then liberated on rupture of schizonts about 7 th

to 9th day of the bites and enter into the blood stream.(Snow et al., 2005). These merozoites

either invade the RBCs or other parenchymal liver cells. In case of P. falciparum and

possibly P. malariae, all merozoites invade RBCs without re-invading liver cells. However,

for P. vivax and P. ovale, some merozoites invade RBCs and some re-invade liver cells

initiating further Exo-erythrocytic schizogony, which is responsible for relapses. Some of the

merozoites remain dormant becoming active later on (Uko et al., 1998).

Erythrocytic schizogony (blood phase) is completed in 48 hrs in P. vivax, P. ovale, and P.

falciparum, and 72 hrs in P. malariae. The merozoites reinvade fresh RBCs repeating the

schizogonic cycles. Erythrocytic merozoites do not reinvade the liver cells. So malaria

transmitted by blood transfusion reproduces only erythrocytic cycle. Some merozoites that
invade RBCs develop into sexual stages (male and female gametocytes). These undergo no

further development until taken by the mosquito.(Snow et al., 2005)

Fig 2.1.Life cycle of Plasmodium species(Agan et al., 2010)
2.4 Epidemiology of malaria

In 2015, approximately 3.2 billion people nearly half of the world's population were at

risk of malaria. Most malaria cases and deaths occur in sub-Saharan Africa(WHO, 2015).

However, Asia, Latin America, and, to a lesser extent, the Middle East, are also at risk. In

2015, 95 countries and territories had ongoing malaria transmission(WHO, 2015).

Some population groups are at considerably higher risk of contracting malaria, and

developing severe disease, than others. These include infants, children under 5 years of age,

pregnant women and patients with HIV/AIDS, as well as non-immune migrants, mobile

populations and travellers (Raimi and Kanu, 2010). National malaria control programmes

need to take special measures to protect these population groups from malaria infection,

taking into consideration their specific circumstances.

According to the latest WHO estimates, released in December 2015, there were 214 million

cases of malaria in 2015 and 438 000 deaths.

Between 2000 and 2015, malaria incidence among populations at risk fell by 37% globally;

during the same period, malaria mortality rates among populations at risk decreased by

60%(WHO, 2015). An estimated 6.2 million malaria deaths have been averted globally since

2001.(WHO, 2004)

Sub-Saharan Africa continues to carry a major share of the global malaria burden. In 2015,

the region was home to 88% of malaria cases and 90% of malaria deaths.

Anopheles mosquitoes lay their eggs in water, which hatch into larvae, eventually emerging

as adult mosquitoes (Walker, 2002). The female mosquitoes seek a blood meal to nurture

their eggs. Each species of Anopheles mosquito has its own preferred aquatic habitat; for

example, some prefer small, shallow collections of fresh water, such as puddles and hoof

prints, which are abundant during the rainy season in tropical countries.
Transmission also depends on climatic conditions that may affect the number and survival of

mosquitoes, such as rainfall patterns, temperature and humidity. In many places, transmission

is seasonal, with the peak during and just after the rainy season. Malaria epidemics can occur

when climate and other conditions suddenly favour transmission in areas where people have

little or no immunity to malaria.

2.5 Diagnosis of malaria

The main process of malaria diagnosis has been the microscopic examination of blood,

utilizing blood films. Although blood is the sample mostly used to make a diagnosis, both

saliva and urine have been investigated as alternative, less invasive specimens (Sutherland

and Hallet, 2009).More recently, modern techniques utilizing antigen tests or polymerase

chain reaction have been discovered, though these are not widely implemented in malaria

endemic regions (Mens et al., 2006). Areas that cannot afford laboratory diagnostic tests

often use only a history of subjective fever as the indication to treat for malaria.

The most economically, preferred, and reliable diagnosis of malaria is microscopic

examination of blood films because each of the four major parasite species has peculiar

characteristics. Two sorts of blood film are traditionally used (Nwonwu et al., 2009). Thin

films are similar to usual blood films and allow species identification because the parasites

appearance is best preserved in this preparation. Thick films allow the microscopist to screen

a larger volume of blood and are about eleven times more sensitive than the thin film, so

picking up low levels of infection is easier on the thick film, but the appearance of the

parasite is much more distorted and therefore distinguishing between the different species can

be much more difficult(Anorlu et al., 2001). With the pros and cons of both thick and thin

smears taken into consideration, it is imperative to utilize both smears while attempting to

make a definitive diagnosis.

For places where microscopy is not available, or where laboratory staff are not experienced

or well equipped at malaria diagnosis, there are commercial antigen detection tests that

require only a drop of blood(Mens et al., 2006). Immunochromatographic tests (also called:

Malaria Rapid Diagnostic Tests, Antigen-Capture Assay or "Dipsticks") have been

developed, distributed and field tested. These tests use finger-stick or venous blood, the

completed test takes a total of 1520 minutes, and the results are read visually as the presence

or absence of colored stripes on the dipstick, so they are suitable for use in the field

(Sutherland and Hallet, 2009).

2.6 Clinical features of Plasmodium species

2.6.1 Plasmodium falciparum

Clinical features

Plasmodium falciparum demonstrates no selectivity in host erythrocytes, i.e. it invades young

and old RBCs cells. The infected red blood cells also do not enlarge and become distorted.

Occasionally, reddish granules known as Maurers dots are observed.

Mature (large) trophozoite stages and schizonts are rarely seen in blood films, because their

forms are sequestered in deep capillaries, liver and spleen.

Peripheral blood smears characteristically contain only young ring forms and occasionally

crescent shaped gametocytes.

Of all the four Plasmodia, P. falciparum has the shortest incubation period, which ranges

from 7 to 10 days (Uko et al., 1998). After the early flu-like symptoms, P. falciparum rapidly

produces daily chills and fever as well as severe nausea, vomiting and diarrhoea (Abeku,

2007). The periodicity of the attacks then becomes tertian (36 to 48 hours), and fulminating

disease develops. Involvement of the brain (cerebral malaria) is most often seen in

P.falciparum infection. Kidney damage is also associated with P. falciparum malaria,

resulting in an illness called black water fever (Layne, 2006). Intravascular hemolysis with
rapid destruction of red blood cells produces a marked hemoglobinuria and can result in acute

renal failure, tubular necrosis, nephrotic syndrome, and death (Snow et al., 2005). Liver

involvement is characterized by abdominal pain, vomiting of bile, hepatosplenomegally,

severe diarrhea, and rapid dehydration.

2.6.2 Plasmodium vivax

Clinical features

P.vivax is selective in that it invades only young immature erythrocytes.

Infected red blood cells are usually enlarged and contain numerous

pink granules or schiffners dots. The trophozoite is ring-shaped but amoeboid in

appearance. After an incubation period (usually 10 to 17 days), the patient experiences vague

flu-like symptoms, such as headache, muscle pains, photophobia, anorexia, nausea and

vomiting. As the infection progresses, increased numbers of rupturing erythrocytes liberate

merozoites as well as toxic cellular debris and hemoglobin in to circulation (White, 2011). In

combination, these substances produce the typical pattern chills, fever and malarial rigors.

The paroxysms may remain relatively mild or may progress to severe attacks, with hours of

sweating, chills, shaking persistently, high temperatures (39oC- 41oC) and exhaustion (White,

2011). Since P.vivax infects only the reticulocytes, the parasitemia is usually limited to

around 2 to 5% of the available red blood cells (Abba et al., 2014).

2.6.3 Plasmodium malariae

Clinical features

In contrast with P. vivax and P. ovale, P. malariae can infect only mature erythrocytes with

relatively rigid cell membranes. As a result, the parasites growth must conform to the size

and shape of red blood cell (Cox, 2002).

This requirement produces no red cell enlargement or distortion, but it results in distinctive

shapes of the parasite seen in the host cell, band and bar forms as well as very compact
dark staining forms. The schizont of P.malariae is usually composed of eight merozoites

appearing in a rosette (Snow et al., 2005).

The incubation period for P. malariae is the longest of the plasmodia, usually 18 to 40 days,

but possibly several months to years. The early symptoms are flu-like with fever patterns of

72 hours (quartan or malarial) in periodicity.

2.6.4 Plasmodium ovale

Clinical features

The incubation period for P.ovale is 16-18 days but can be longer (Snow et al., 2005)

Clinically, ovale malaria resembles vivax malaria with attacks recurring every 48-50 hours.

There are however, fewer relapses with P.ovale. Less than 2% of RBCs usually become

infected (Menendez, 2001). P. ovale is similar to P. vivax in many respects, including its

selectivity for young, pliable erythrocytes. The host cell becomes enlarged and distorted,

usually in an oval form. Schiffners dots appear as pale pink granules.

2.7 Management of malaria

2.7.1 Chemotherapeutic control

The use of chemotherapy in the treatment of malaria has improved over the years, According

to World Health Organisation guidelines (WHO, 2010) artemisinin-based combination

therapies(ACTs) are the recommended first-line antimalarial treatments for uncomplicated

malaria.The following ACTs are recommended by WHO: Artemether and lumefantrine,

Artesunate and amodiaquine, Artesunate and mefloquine, Artesunate and sulfadoxine-

pyrimethamine, Dihydroartemisinin and piperaquine.

Also the use of second-line antimalarial treatment, was recommended by WHO, when initial

treatment does not work, such as: Artesunate plus tetracycline or doxycycline, Quinine plus

tetracycline, clindamycin or doxycycline (WHO,2014).

In pregnant women, the recommended first-line treatment during the first trimester is

chloroquinine and clindamycin for a week (WHO,2010). Artesunate plus clindamycin for a

week is indicated if this treatment fails.(WHO, 2010). Although recent updates as

recommend the use of intermittent preventive treatment in pregnancy(IPTp) with

sulfadoxine-pyrimethamine as part of antenatal services (WHO, 2015).

2.7.2 Biological control

Biological control involves the use of natural enemies to manage mosquito populations.

An effective biological control agent is the predatory fish that feeds on mosquito larvae

known as mosquitofish(Gambusia affinis),Tilapia and cyprinids (Durden and Mullen,2002).

Although the direct introduction of these fishes into the ecosystem have had disastrous effect

around locations where they were used, but under controlled system its effect is less (Walker,

2002).

The use of oil drips from cans or barrel was a common nontoxic antimosquito

measure(Durden and Mullen, 2002). The thin layer of oil on top of the water prevents

mosquito breeding in two ways : mosquito larvae in the water cannot penetrate the oil film

with their breathing tube , and so drown and die, also adult mosquitoes do not lay eggs on

oiled water. The introduction of large number of sterile males is another approach in

reducing mosquito numbers.

The control of adult mosquitoes with the use of pesticide is the most familiar aspect of

control known worldwide.

 CHAPTER 3

MATERIALS AND METHODS

3.1 STUDY AREA

This study was conducted in the Zonal Hospital, Bori in Khana Local Government Area of

Rivers State , Nigeria. The hospital is a government-owned institution that offer antenatal

care(ANC), preventive and curative services at affordable costs for the middle and low-

income population. The health facility is highly accessible, facilitating utilisation of ANC

services.

The Bori Area is the traditional headquarters of the Ogoni people. Bori serves as a

commercial centre for the Ogoni, Andoni, Opobo, and other ethnic nationalities of the Niger

Delta . The Bori Urban Area has many adjoined communities including the Bua Kaani,

Yeghe and Bo-Ue people. It is located at coordinates of Latitiude:4oN and

Longitude:7o(Uneke, 2008). It has an equatorial climate made up of a long rainy season

which runs from March to October with maximum rainfall usually recorded in the months of

August and September (Uneke, 2008). The dry season runs from November to

February(Uneke, 2008).

The majority of the population in Bori urban area are into farming, fishing, petty trading and

a few are government civil servants. Most of the component communities are rural in nature.

The predominant occupation such as farming and fishing exposes them more to the bite of

mosquitoes. Similarly, environmental factors like presence of overgrown grasses, stagnant

water, blocked drainages around most vicinities greatly influence the transmission of malaria

in the area.

This study was conducted between April and late June,2016.

3.2 STUDY POPULATION

A total of 200 pregnant women attending the antenatal clinic of the Zonal Hospital, Bori,

were enrolled after their consent has been sought. Questionnaires were then administered

requesting information on age, basic medical history and gestational age.

3.3 ETHICAL CONSIDERATION

Ethical clearance was obliged and obtained from the Department of Medical Laboratory

Science of the Rivers State University of Science and Technology, Nkpolu-Oroworukwo,

Port Harcourt and also given by the Zonal Hospital Hospital, Bori in Khana Local

Government Area, Rivers State, Nigeria. Informed consent was obtained from all study

subjects.

3.4 SAMPLE COLLECTION

The method of blood collection adopted is the performance of venipuncture which is the

surgical puncture of a vein for the purpose of withdrawal of blood.

The subject was correctly identified as been a pregnant woman and instructed to sit on a

chair. The arm was examined for a prominent vein. A tourniquet was applied 2 inches above

the selected puncture site. The arm was cleaned in a circular fashion using 70% alcohol

beginning at the puncture site and working outward, then allowed to dry, using a sterile new

2ml syringe and needle for each subject. The needle was inserted swiftly and gently through

the skin and into the vein, using the plunger; 1.0ml of blood was gently withdrawn. The

blood samples collected were transferred into an EDTA bottle, agitated to mix, labelled and

numbered for proper identification. The collected samples were packed in an ice box and

taken to the Medical Laboratory at Rivers State University of Science and Technology, Port

Harcourt for proper analysis.

3.5 BLOOD FILM PREPARATION

3.5.1 Thin blood film

From the collected blood samples, a drop of blood from each, was placed on a grease free

glass slide. A clean spreader , held at 45o angle is brought toward the drop of blood on the

glass slide. The drop of blood was allowed to spread along the entire width of the spreader

slide, while holding the spreader at the same angle, it was pushed forward rapidly and

smoothly. The slide was then labelled and allowed to air dry.

3.5.2 Thick blood film

From the collected blood samples, two small drops of blood from each was placed at the

centre of a grease free glass slide. With an applicator stick, the drops were mix in a circular

motion over an area of about 1-2cm in diameter. The slide was then labelled and allowed to

air dry.

3.6 STAINING PROCEDURE FOR THICK FILM

The slides having the dried thick films were placed on a staining rack. Giemsa stain was

prepared by making a dilution of 1 in 30 ,by mixing 1ml of stain and 29ml of buffered water

of pH 7.2. The slides were covered with diluted Giemsa stain and allowed to act for

30minutes,then it was gently washed off with buffered water and allowed to air dry in a

vertical position.

Drops of immersion oil were added to the dried stained slides each and were viewed with the

x100 objective lens of a compound microscope.

3.7 STAINING PROCEDURE FOR THIN FILM

The dried thin films were placed on a staining rack. Giemsa stain was prepared by making a 1

in 10 dilution, mixing 1ml of stain and 9 ml of buffered water of pH 7.2. The thin film was

fixed in methanol for 30 seconds, then allowed to dry. The film was later flooded with the
diluted Giemsa stain for 10 minutes, then it was gently washed with buffered water and

allowed to air dry in a vertical position.

Drops of immersion oil were added to the dried stained slides each and were viewed with the

x100 objective lens of a compound microscope.

3.8 MICROSCOPIC EXAMINATION

The blood films were examined microscopically as stated earlier using x100 oil immersion

objective lens as described by Cheesebrough(2000).

The thick film were used to determine the parasite densities while thin films were used to

identify the infective stages and confirm the parasite species. The malaria parasite intensity

was recorded in accordance with WHO as stated by Raimi et al., 2010.

3.9 DATA ANALYSIS

The results were shown as simple percentages, such as percentage prevalence. Some

statistical significance of variables was evaluated using the CHI-square(X2).

 CHAPTER 4

RESULTS

Table 1: Age distribution of malaria parasite in pregnant women of those positive and

negative to malaria

.
Age,years No. examined,n Positive for malaria,n (%) Negative for malaria,n (%)

21-25 30 19 (9.5) 11 (5.5)

26-30 63 46 (23) 17 (8.5)

31-35 79 68 (34) 11 (5.5)

36-40 13 8 (4) 5 (2.5)

41-45 10 4 (2) 6 (3)

46-50 5 3 (1.5) 2 (1)

Total 200 148 (74) 52 (26) .

*No.= Number

Table 1 shows that pregnant women between age group 31-35years had the highest

number of pregnant women and also the highest positive cases of malaria,(n= 68) with 34%

as percentage of prevalence at that group. Those in the age group 46-50 years had the lowest

number of pregnant women as well as the lowest positive cases of malaria,(n= 3) with 1.5%

as its percentage of incidence.

 % Prevalence

40

35

30

25

20

15

10

0
21-25 26-30 31-35 36-40 41-45 46-50 Age group

Fig 4.1:Bar chart showing age distribution of malaria parasitaemia in pregnant women
Table 2: Distribution of malaria in pregnant women based on the use of Insecticide

Treated Nets(ITN) .

.
No. examined Positive cases % of positive cases

Use of ITN 88 68 34

Do not use ITN 112 80 40

Total 200 148 74 .

*No. = Number

Table 2 indicates that from the total 148 positive cases for malaria of pregnant women, those

using insecticide treated nets had less positive cases of 34% as compared to the pregnant

women who do not having 40%.

% prevalence
41

40

39

38

37

36

35

34

33

32

31
Use of ITN Do not use ITN

Fig 4.2: Bar chart showing distribution of pregnant women that make use of Insecticide

Treated Nets and those that dont

Table 3: Distribution of malaria among pregnant women based on gestational period

.
No. of examined No. of positive % Prevalence

First trimester 57 45 22.5

Second trimester 98 81 40.5

Third trimester 45 22 11

Total 200 148 74 .

From the table 4, the pregnant women in their Second trimester showed a higher percentage

of malaria infection of 40.5%, while the lowest were those in their third trimester with 11%.
% Prevalence

45

40

35

30

25

20

15

10

0
First trimester Second trimester Third trimester Gestational period

Fig 4.3: Bar chart showing distribution of malaria parasitaemia among pregnant women

based on gestational period

Table 4: Prevalence of malaria among pregnant women based on drug used

.
No. of examined No. Positive % Prevalence

Prophylaxis 84 55 27.5

Malariacidal 44 24 12

Take no drug 72 69 34.5

Total 200 148 74 .

*No. = Number

Table 4 shows that the patients who refused to take drug due to had the highest prevalence

rate of 34.5%, followed by those on prophylaxis (27.5%).

 %P revalence

40

35

30

25

20

15

10

0
Prophylaxis Malariacidal Take no drug Drug use

Fig 4.4; Bar chart showing distribution of malaria parasitaemia among pregnant women

based on drug use

Table 5; Gravidity distribution of malaria among pregnant women

.
Gravidity No.examined No.positive %prevalence

Primigravidae 120 97 48.5

Multigravidae 80 51 25.5

Total 200 148 74 .

Table 5 shows that pregnant women with primigravidae have a higher percentage(48.5%) of

positive cases as compared to the multigravidae pregnant women (25.5%).

 %prevalence

60

50

40

30

20

10

0
Primigravidae Multigravidae

Fig 4.5: Bar chart showing distribution of malaria parasitaemia among pregnant women

based on gravidity.
Table 6: Chi square table of positive and negative cases of malaria among pregnant

women using age distribution

.
Age 21-25 26-30 31-35 36-40 41-45 46-50

Observed positive cases 19 46 58 8 4 3

Expected positive cases 22.20 46.62 58.50 9.62 7.40 5.00

Observed negative cases 11 17 11 5 6 2

Expected negative cases 7.80 16.40 2.50 3.40 2.60 0.52

Using level of significance at 0.05

degree of freedom(df) = 5, calculated expected value, X2 =19.78

The calculated value of 19.78 exceeds the value of 11.07 seen on the CHI- square table at the

0.05 level of significance, therefore ,P < 0.05, indicating that the level of positive cases

among pregnant women of all age groups is statistically signicant from the negative cases.
 CHAPTER 5

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 DISCUSSION

The results of the study reported in this work clearly indicates that malaria is a dangerous

infection associated with pregnant women. The study showed that P. falciparum was the

species responsible for all the cases of parasitaemia in pregnant women studied and living in

the study communities and were attending antenatal care(ANC) at the Zonal Hospital, Bori.

In this study, out of the 200 pregnant women, 148 were positive to malaria and 52 were

negative to malaria. From the 148 positive cases, 34% belong to age group (31-35) had the

highest level of parasitaemia and number of pregnant women, while pregnant women of age

group 36-40 and above had the least number of pregnant women and least incidence of

parasitaemia, showing 36-40 having 4%. age group (41-45) having 2% and 46-50 having

1.5%. This result supports the existing knowledge that high incidence of malaria at lower

ages , that is mid thirties and below, and low incidence at higher ages that is, late thirties and

above is due to the existence of natural immunity to infectious disease like malaria (Khan et

al., 2006), which the pregnant women acquired as the age increases.

Malaria parasitaemia occurred more in pregnant women in the second trimester (40.5%) from

the Table 3, which is in line with studies where the highest level of malaria parasites was

recorded in the second and early third trimester (Lander et al., 2002). Although other studies

have shown an increase in parasitaemia in the third trimester according to Adefisoye et al.,

2007, in their study they stated that the high prevalence in the third trimester was due to

fewer subjects enrolled for the study and their late registration for antenatal care.

The questionnaires given to the respondents , showed that the existence of Insecticide Treated

Nets (ITN) was known but from the Table 2, only 88 subjects made use of it of which 34%
were positive for malaria, 112 of the subjects did not use it and 40% where positive to

malaria. Though most of the 88 subject that use the net do not use it frequently and were

subjected to other environmental factors like, overgrown grasses in their surroundings,

stagnant water and going out at night which predisposes them to mosquito bite, this

corresponds with the work done by Chukwuocha et al.,(2010).

On the use of drug by the pregnant women against malaria from data gathered based on Table

4, 34.5% of the pregnant women were positive for malaria and these group did not take any

form of drug either prophylactic(Intermittent prophylactic treatment) or malariacidal

treatment, hence had a higher percentage incidence of malaria. Those on malariacidal drugs

had lower prevalence of 12%.

An analysis of malaria in pregnancy in Africa revealed that parasiteamia is significantly

common and heavier in primigravidae than multigravidae (McGregor,2005). This study

showed high level of infection in primigravidae (Table 5). This is because in an area where

transmission is high and the level of acquired pregnancy immunity against malaria is

expected to be significant, primigravidae is more affected (McGregor,2005). This has

therefore corroborated the findings in these study indicating a positive parasitaemia of 48.5%

for primigravidae pregnant women, a higher value as compared to the multigravidae group

having 25.5%.

5.2 CONCLUSION

The main epidemiological factor to P. falciparum infection in pregnancy should be

considered in relation to the endemic malaria conditions under which women are living.

Pregnancy is also one of the factors affecting the rate of malarial parasite infection in women

living in malaria endemic communities. Malaria should therefore be known as a global

priority in health care more so in pregnancy. Pregnant women in malaria endemic regions,

with or without fever should be screened for malaria parasitaemia. Timely diagnosis as well
as good antimalarial treatment, adequate health education about malaria, supportive services

and sustained preventive measures, if effectively implemented should essentially reduce the

scourge of malaria and its consequences in pregnancy.

5.3 RECOMMENDATIONS

The presence of bush and/or standing water in house surroundings increases the risk

of P. falciparum infection and malaria in pregnancy, hence should be cleared

wherever found.

Prompt malaria diagnosis and proper treatment as well as early ANC care attendance

to avoid adverse consequences of early infection in pregnancy is justified.

Education on early ANC attendance and environmental sanitation are important

public health targets for malaria control in pregnancy in this setting.

Responses on perceived preventive and control measures of malaria among pregnant

women in the study area suggested that antenatal care and health education,

(Intermittent Prophylactic Treament) IPT with sulfadoxine pyrimethamine, constant

use of insecticide nets, environmental sanitation, use of personal protective clothing

and other mechanical control methods (use of fan) would all be effective in

controlling malaria. The World Health Organization however recommends

administration of two or more doses of a safe, effective anti-malarial after the end of

the first trimester to all pregnant women (WHO, 2014).

Although the development of malaria vaccine has being in the works by various

pharmaceutical research institute, infected individuals never develop a complete

immunity making the prospects dim but this shouldnt deter, as more work is to be

done by researchers as a breakthrough would definitely come in this area of

vaccination.
 REFERENCES

Abba, K., Deeks, J.J., Olliaro, P., Naing, C.M., Jackson, S.M., Takwoingi, Y., Donegan, S.,

and Garner, P. (2011). Rapid diagnostic tests for diagnosing uncomplicated P.

falciparum malaria in endemic countries. Journal of Infectious Diseases,34(8),67-71.

Abeku, T.A. (2007). Response to malaria epidemics in Africa. Emerging Infectious Diseases,

14 (5), 681686.

Achidi, E.A., Kuoh, J.T., Minang, B., Ngum, B.M., Motaze, M.J., and Troye-Blomberg,

M.(2005). Malaria infection in pregnancy and its effects on haemoglobin levels in

women from a malaria endemic area of Fako Division South West Province,

Cameroon. Journal of Obstetrics and Gynaecology, 25(3): 235-240

Adefisoye, O.A., Adeyeba, O.A., Hassan, W.O., and Oyeniran, O.A.(2007). Prevalence of

malaria parasites infection among pregnant women in Oshogbo, South west, Nigeria.

American European Journal of Scientific Research, 2(1): 43-45.

Agan T., Ekabua J., Udoh A., Ekanem E., Efiok E., Mgbekem M.(2010) Prevalence of

anemia in women with asymptomatic malaria parasitemia at first antenatal care visit

at the University of Calabar Teaching Hospital, Calabar, Nigeria. International

Journal on Womens Health. 2(4):22933.

Anorlu, R.I., Odum, C.U., and Essien, E.E. (2001). Asymptomatic malaria parasitaemia in

pregnant women at booking in a primary health care facility in a periurban

community in Lagos, Nigeria. African Journal of Medicine and Sciences, 30: 39-41.

Cheesebrough, M. (2006). District Laboratory Practice in Tropical Countries. 2nd Edition,

Part 2 New York: Cambridge University Press, pp: 440.

Chukwuocha U.M., Dozie I.N.S., Onwuliri C.O.E., Ukaga C.N., Nwoke B.E.B., Nwankwo

B.O.(2010). Perceptions on the use of insecticide treated nets in parts of the Imo
 River Basin, Nigeria: Implications for preventing malaria in pregnancy. African

Jorunal on Reproductive Health,14(1), 117-128.

Cox, F. (2002). History of human parasitology. Clinical Microbiology Reviews, 15 (4), 595

612

Durden L.A., and Mullen, G.L. (2002). The species of mosquito. Medical and veterinary

entomology,2(7),31-36.

Enato,E.F., Mens, P. F., Okhamafe, A. O., Okpere, E. E., Pogoson, E., and Shalling,

H.D.(2009). Plasmodium falciparum malaria in pregnancy: prevalence of peripheral

parasitemia, anaemia and malaria care seeking behavior among pregnant women

attending two antenatal clinics in Edo state, Nigeria Journal of Obstetrics and

Gynaecology, 29(4): 301-316.

Federal Ministry of Health,(2000). Malaria situation analysis document in Nigeria;Malaria

Report and Surveillance. Retrieved from http://www.health.gov.ng/ (Retrieved 30

June,2016).

Khan, K.S., Wojdyla, D., Say, L., Gulmezoglu, A.M., and Van Look, P.F. (2006). WHO

analysis of causes of maternal deaths: a systematic review. Lancet. 367: 1066-1074.

Lander, J., Leroy, V., Simonon, A., Karita, E., Bogaerats, J., Clercq, A.D., Van de Perre, P.,

and Dabis, F. (2002). HIV infection, malaria and pregnancy: A prospective cohort

study in Kigali, Rwanda. American Journal Tropical Medicine and

Hygiene.,66(3),56-60

Layne, S.P.(2006). Principles of Infectious Disease Epidemiology. Journal of disease

epidemiology,3(8),45-49.

McGregor, L.A. (2004). Epidemiology, malaria and pregnancy. American Journal of

Tropical Medicine and Hygiene, 33: 517-525.

Menendez, C., (2001). The effect of malaria during pregnancy on infant mortality in an area

of low malaria transmission. American Journal of Medicine and Hygiene, 15(5),

459-469.

Mens P.F.,Schoone G.J.,Kager, P.A.,Schallig, H.D. (2006). Detection and identification of

human Plasmodium species with real time quatitative nucleic acid sequence based

amplification. Malaria Journal, 5(80),80-83.

Nadjm, B., and Behrens, R.H. (2012). Malaria: An update for physicians. Infectious Disease

Clinics of North America, 26(2), 243259.

Nwangha, U.I.,Ugwu,V.O.,Nwagha T.U., and Anyaehie,B.U (2009). Asymptomatic

Plasmodium parasitaemia in pregnant women: almost a decade after Roll Back

Malaria. Transactions of the Royal Society for Tropical Medicine and

Hygiene,103(1): 16-20.

Nwonwu, E.U., Ibekwe, P.C., Ugwu, J.I., Obarezi, H.C., and Nwagbara, O.C.(2009).

Prevalence of malaria parasitemia and malaria related anaemia amongst pregnant

women in Abakaliki, Southeast Nigeria. Nigeria Journal of Clinical Practice., 2009,

12(2),182186.

Ofori, M.F., Ansah, E., Agyepong, I., Ofori-Adjei, D., Hviid, L., Akanmori, B. (2009).

Pregnancy-associated malaria in a rural community of Ghana. Ghana Medical

Journal.43,1318.

Pates, H., and Curtis, C. (2005). Mosquito behaviour and vector control. Annual Review of

Entomology, 50(3),5370.

Raimi, O.G., Elemo, B.O., and Raheem, L. (2004). Malaria in Pregnancy: Serum Enzyme

Level in Pregnant Malarial Patients in Lagos. Nigeria Journal of Science

Technology, 3(3),60-63.
Raimi,O.G., and Kanu, C.P.(2010). The prevalence of malaria infection in pregnant women

living in a suburb of Lagos, Nigeria. African Journal of Biochemistry

Research,4(10),243-245.

Ricci, F. (2012). Social implications of malaria and their relationships with poverty.

Mediterranean Journal of Hematology and Infectious Diseases, 4(1),21-24.

Reiter, P. (1999). From Shakespare to Defoe; malaria in England in the little ice Age.

Emerging Infectious Diseases,6(1),1-11.

Saeed, I.E.,and Ahmed, E.S. (2003). Determinants of malaria mortality among displaced

people in Khartoum state, Sudan. East Mediterranean Health Journal,9(4),593-599.

Steketee, R.W., B.L. Nahlen, M.E. Parise and C. Menendez, (2001). The burden of malaria in

pregnancy in malaria endemic areas. American Journal of Tropical Medicine and

Hygiene, 64(1-2): 28-35.

Snow, R.W., Gouws, E., and Korenromp, E.L. (2005). Paediatric mortality in Africa:

Plasmodium falclparum malaria as a cause or risk? American Journal of Tropical

Medicine and Hygiene. 71,16-24.

Sutherland, C.J., and Hallet, R. (2009). Detecting malaria parasites outside the blood. Journal

of Infectious Disease,199(11),1561-1563.

Tan, S.Y., and Sung, H. (2008). Carlos Juan Finlay (18331915): Of mosquitoes and yellow

fever. Singapore Medical Journal, 49 (5), 370382

Uko, E.K., Emeribe, A.O., and Ejezie G.C.(1998). Malaria Infection of the placenta and Neo-

Natal Low Birth Weight in Calabar. Journal of Medical Laboratory Science, 7, 7-10.

Uneke, C.J.(2008). Assessment of malaria in pregnancy using rapid diagnostic tests and its

association with HIV infection and haematologic parameters in south-eastern

Nigeria. Haematologica,93:143144.
Walker, K.(2002). A review of control methods for African malaria vectors. Journal of

Entomological Research,34(8),45-49.

Webb Jr JLA (2009). Humanity's Burden: A Global History of Malaria. Cambridge

University Press. ISBN 978-0-521-67012-8

White, N.J. (2011). Determinants of relapse periodicity in Plasmodium vivax malaria.

Malaria Journal, 10(5), 297-298.

World Health Organization. (2004). A strategic framework for malaria prevention and control

during pregnancy in the Africa,second edition. Retrieved from

www.who.int/malaria/en (Retrieved 20 June, 2016).

World Health Organization, (2010). Guidelines for the treatment of malaria. Retrieved from

www.who.int/malaria/publications/wmr/ (Retrieved 27 June, 2016).

World Health Organization, (2014). World Malaria Report 2014. Retrieved from

www.who.int/malaria/publications/wmr/ (Retrieved 4 July, 2016).

World Health Organization, (2015). World Malaria Report 2015. Retrieved from

www.who.int/malaria/publications/wmr2/ (Retrieved 10 July, 2016).

 APPENDIX I

Intensity of malaria parasitaemia among pregnant women

Intensity No. of positive Percentage

+ 97 48.5

++ 43 21.5

+++ 7 3.5

++++ 1 0.5

Total = 148 Total = 74

This shows the total number of positive cases

Negative cases = control

Grading of intensity

+ = 1 10 parasites/100 high power field

++ = 11-100 parasites/ 100 high power field

+++ = 1 -10 parasites/high power field

++++ = >10 parasites/ high power field

 APPENDIX II

Distribution of intensity of malaria parasitaemia among pregnant women based on age

group.

Age group Degree of malaria parasitaemia

+ ++ +++ ++++

21-25 13 3 3 Nil 19

26-30 20 22 3 1 46

31-35 54 12 2 Nil 68

36-40 6 2 Nil Nil 8

41-45 2 2 Nil Nil 4

46-50 1 2 Nil Nil 3

97 43 7 1 Total 148

All negative pregnant women, control = 52

Total number of all pregnant women = 200

 APPENDIX III

Frequency distribution table of positive cases in pregnant women based on age group

Age group Midpoint of Positive cases(f) fx x2 fx2

age(x)

21-25 23 19 437 529 10051

26-30 28 46 1288 784 36064

31-35 33 68 2244 1089 74052

36-40 38 8 304 1444 11552

41-45 43 4 172 1849 7396

46-50 48 3 144 2304 6912

f = 148 fx = 4589 fx 2=

146027

Estimated mean of positive cases = fx = 4589 = 31.0

f 148

Standard deviation = fx2 - fx = 146027 (4589)2

f f 148 (148)

= 986.69 961.52 = 25.15

Standard deviation = 5. 02
 APPENDIX IV

Percentage prevalence of malaria positive cases in pregnant women based on use of ITN

No. examined Positive cases % of positive cases

Use of ITN 88 68 34

Do not use ITN 112 80 40

Total 200 148 74

P- value = 0.192

Statistically the use of ITN is not significant in relation to positive cases

Percentage prevalence for use of Insecticide Treated Nets

Positive cases x 100
Total examine

68 x 100 = 34%
200
Percentage prevalence for pregnant women that do not use Insecticide Treated Nets

80 x 100 = 40%
200
 APPENDIX V

No. of examined No. of positive % Prevalence

First trimester 57 45 22.5

Second trimester 98 81 40.5

Third trimester 45 22 11

Total 200 148 74

p-value = 0.134

statistically gestational age is not significant in relation to positive cases

First trimester, percentage prevalence:

number of positive case x 100
Total number of subjects

45 x 100
200 = 22.5%
Second trimester, percentage prevalence:

81 x 100
200 = 40.5%

Third trimester, percentage prevalence :

22 x 100
200 = 11%
 APPENDIX VI

A copy of questionnaire used in data gathering

RIVERS STATE UNIVERSITY OF SCIENCE AND TECHNOLOGY,NKPOLU-

OROWORUKWO, PORT HARCOURT

I am a Final year student of the department of Medical Laboratory Science of

RSUST,carrying out a research project on the Epidemiology of malaria parasite among
pregnant women using Zonal Hospital, Bori as a case study.Please any information given
therein would be treated with utmost confidentiality.

QUESTIONNAIRE
(please tick Yes or No where appropriate)

1. What is your name

2. What is your age.

3. What is your local govt. area.

4. Number of months pregnant.

5. Have you been diagnosed of malaria recently..yes/no

6. Do you know or have a copy of the drug prescription you took.

7. How many times have you been diagnosed of malaria during your
pregnancy..

8. When last did you take antimalarial drug..

9. Is this your first pregnancy..yes/no

10. Do you use insecticide treated nets(ITN).yes/no

Project supervisor.Dr(Mrs) G.N. Wokem

Project student: Ogbu, Jason Cheta