ASSESSMENT OF USE OF INDOOR RESIDUAL SPRAYING (IRS) AND OTHER MALARIA VECTORCONTROL MEASURESAMONG MEDICAL STUDENTS IN ABIA STATE UNIVERSITY, UTURU

CHAPTER ONE INTRODUCTION 1.1 BACKGROUND: Malaria infection is one of the major causes of death in African continent.1 The causative organism of malaria is a parasite of genus Plasmodium and transmitted to man by infected Female Anopheline mosquito.2 The clinical features of malaria vary from mild to severe and complicated according to species of parasite present and the patient’s state of immunity. Malaria parasite moves as sporozoites in mosquito which is injected into man during blood meal it undergoes an exoerythrocytic schizogony in the liver later on an erythrocytic schizogony in red blood cells, which release the merozoites that subsequently becomes the gamaetocytes, taken up during blood meal by the female anopheles mosquito to continue the life cycle again. Malaria is endemic in many countries in sub-Saharan Africa, South East Asia and to a lesser extent in the western Pacific and Eastern Mediterranean thus Africa accounting for 90%.3 Despite being a high burden amongst children of under five, pregnant women, elderly and people of low socio economic status, it remains a holoendemic disease since it affects all ages.4 In Nigeria, it is hyperendemic due to certain constraints to malaria control and eradication like inadequate funding of the health sector and impact on health behaviour, lack of basic living infrastructure to malaria exposure and disease, systemic structural violence that challenges malaria eradication.4 In 2019, six countries accounted for approximately half of all malaria death worldwide: Nigeria (23%), Democratic Republic Of Congo (11%), United Republic of Tanzania (5%), Burkina Faso(4%), Mozambique(4%), Niger(4% each).5 The severity and endemic nature of this disease has thus caught the eyes of the World Health Organization as well as other bodies like UNICEF, UNDP and the World Bank, hence the initiation of “ROLL BACK Malaria Initiative” in 1998.2 The three primary interventions that should be scaled up by countries in order to tackle malaria include: 1. Diagnose malaria cases and treatment with effective medicines. 2. Use of Indoor Residual Sprays (IRS) as a major means to tackle the vector. 3. Distribution of Insecticide Treated Nets (ITN) to achieve full coverage of population at risk of malaria. INDOOR RESIDUAL SPRAYING (IRS) This is the application of long lasting chemical insecticides on the walls and roofs of all houses and domestic stuff in a given area, in order to kill the adult mosquitoes. It is the most effective against Indoor feeding (Endophagic) and Indoor resting (Endophilic) vectors. Basically, it was the primary malaria control method used during the Global Malaria Eradication Campaign (1955- 1969), the campaign did not achieve its standard objective but 37 of the 143 countries that were endemic in 1950 were free of malaria by 1978 and there was a sharp reduction in the burden of disease in other countries.6 The difference between Indoor Residual Spraying (IRS) and other malaria vector control measures like the use of Insecticide Treated Nets (ITN) is the point at which they work, with IRS having its greatest impact after feeding when the anopheline mosquito is more likely to rest on a sprayed surface and thus pick up a lethal dose of insecticide therefore preventing its transmission of malaria parasite to others in the vicinity.6 Actions of Indoor Residual Sprays include; • Repelling • Irritation • Killing N/B: Those with high killing action are usually preferred to others.6 CHARACTERISTICS OF A GOOD INDOOR RESIDUAL SPRAYING (IRS) • Residual Effect: Having long lasting effect on a given surface and high toxicity to vector (mosquitoes). • Efficacy: Female anopheline must be susceptible to the IRS. • Correct Formulation: Optimum effectiveness of IRS can be achieved by spraying the right formulation on the right type of surface. • Stability: IRS selected should be stable during transportation and storage at room temperature and minimum ventilation. • Safety: Despite being inherently hazardous, when properly applied it should pose no damage to the household. • Acceptability: This may vary with location as they have faced resistance by several households due to its smell. • Cost: Should not be too expensive. CLASSIFICATION AND COMPOUNDS OF INSECTICIDE According to WHO, the major class of IRS includes: 1. Carbamates (C): Bendiocarb, Propoxour 2. Organochlorines (OC): DDT 3. Organophosphates (OP): Malathion, Fenitrothion, Primiphos-methyl 4. Pyrethroids (PY): alpha-cypermethrin, delta-methrin, lamda-cyhalothrin, Etofenprox, Bifenthrin and Cyfluthrin.6 Other methods for the control of malaria vector include; • Use of Insecticide Treated Nets (ITN): This is the most widely adopted preventive measure against malaria.4 They are mosquito nets treated with an insecticide that kills mosquitoes that come in contact with it, or repels them. It can be Long Lasting ITN, Conventionally Treated Nets, Pyrethroid + PBO Combination Nets, etc. • Biological control: They include use of fungi (e.g Laegenidium giganteum) or mermithid nematodes (e.g Romanomermis culicivoras), pararsites that can kill larva mosquitoes but are not efficient for mosquito control and not widely used.7 • Clearing of breeding sites of mosquitoes like stagnant waters and bushes. • Use of protective anti-mosquito cream (mosquito repellant). • Use of protective clothing. • Sterile male release. • Genetic modification of malaria vector. • Use of vaccine: eg RTS,S/AS01 vaccine, Whole sporozoites (PfSPZ) vaccines, etc.8 1.2 PROBLEM STATEMENT: Malaria is a global public health problem that causes massive morbidity and mortality and poses a higher burden of disease especially in the sub-Saharan Africa region.9 It is known to affect all ages and sexes with some population groups considered as having a higher risk of contacting 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.5 According to Centre for Disease Control CDC, pregnant women lose some of their immunity and are prone to malaria infection because of the changes in women’s immune systems during pregnancy and the presence of placenta with new places for parasites to bind.10 Also, it is known to cause significant economic losses and can decrease the gross domestic profit (GDP) by as much as 1.3% in countries with high levels of transmission.10 Despite decades of control activities, malaria continues to cause more deaths than any other parasitic disease worldwide.11 Over 219 million cases and 435,000 malaria-related deaths are estimated to have occurred globally in 2017, and approximately half of the global population is believed to be at risk of malaria.12 According to the recent malaria report released on 30th November 2020, an estimated number of malaria deaths stood at 409,000 in 2019, compared with 411,000 deaths in 2018 with children less than 5 years accounting for 67% (274,000) deaths in 2019.5 Globally, IRS protection declined from a peak of 5% in 2010 to 2% in 2019 with decrease seen across all WHO regions, apart from the WHO Eastern Mediterranean Region. This decline in coverage occurred as countries switched from pyrethroid insecticides to more expensive alternatives to mitigate mosquito resistance to pyrethroids.3 Factors that have contributed to the reduced use of IRS include; government commitment and financing to sustain these efforts over the long term, concerns on insecticide resistance, community acceptance, and fears of its harmful effects and toxicity on the environment and on human health.11 1.3 JUSTIFICATION OF STUDY: The aim of this study is to access the use of IRS and other malaria vector control measures among medical students at Abia State University, Uturu in using indoor residual sprays and other malaria vector control measures. Since malaria is endemic in Nigeria, any study or research that aids in the understanding of how to prevent its transmission is important. Malaria has contributed to the reduction in the general and physical well being of students and also has a significant financial and human resource effect too. This research will most importantly access each student’s awareness on the various symptoms of malaria as well as the strategies they use to avoid malaria transmission. Awareness campaigns may be designed based on the findings from this study thus potentiating a reduction in the morbidity and mortality rates of malaria among medical students and the general population at large. 1.4 RESEARCH QUESTIONS: 1. What is the background knowledge of the students on malaria transmission and control? 2. What is the attitude of students towards the use of IRS as a means to control malaria vector? 3. What are the other malaria vector control measures used by the students? 4. What factors influence the choice of IRS and other malaria vector control measures among the students? 1.5 GENERAL AND SPECIFIC OBJECTIVES 1.5.1 GENERAL OBJECTIVE: To assess the use Indoor Residual Spraying (IRS) and other malaria vector control measures among Medical students in Abia State University, Uturu. 1.5.2 SPECIFIC OBJECTIVES: 1. To assess the background knowledge of the students on malaria transmission and control. 2. To determine the attitude of students towards the use of Indoor Residual Spraying as a means to control the malaria vector. 3. To determine other methods of malaria vector control used by the students. 4. To identify the factors influencing the choice of IRS and other malaria vector control measures among the students. CHAPTER TWO LITERATURE REVIEW 2.1 OVERVIEW Malaria prevention through vector control still remains the mainstay of reducing malaria transmission among students, due to its safety, efficacy, availability, affordability and accessibility. Indoor Residual Spraying and Insecticide Treated Nets are the two main forms of vector control recommended by WHO due to their effectiveness in a wide range of circumstances, thus these gains are being threatened by emerging resistance of these vectors to insecticides calling for an effective insecticide resistance management strategies to reduce its transmission in the population.3 2.2 BACKGROUND KNOWLEDGE OF STUDENTS ON MALARIA TRANSMISSION AND CONTROL In a study done on Youth Knowledge, Attitude and Practices about malaria in district of Layyah Punjab, 200 respondents were selected through random sampling where the categories of youth included 39 (19.5%) secondary education level, 68 (34%) college education level and 93 (46.5%) university education level which had the majority of the responses. On the basis of where they heard about malaria, 11.5% heard about malaria through poster that displayed on walls and other places, 8.5% responded heard about malaria from newspaper, 14.5% from radio, 4.5% heard from health facility, 10% were through health community meeting, 8.5% heard in malaria campaign and 42.5% heard about malaria on TV. Regarding how malaria is being transmitted, 189 (94.5%) responded that malaria was transmitted through mosquito bites and 11(5.5%) had responded that malaria was transmitted through use of stagnant water. Regarding to the most common signs and symptoms in malaria transmission, 2.5% respondents answered that the most common sign and symptoms in malaria infection is headache. 54.5% respondents said it was high temperature, 8.5% respondents answered chills, 8.5% respondents answered vomiting, 14.5% respondents answered body pain and 11.5% respondents answered loss of energy. Regarding prevention, 11.5% respondents had strongly agreed that malaria can be prevented, 11.5% respondents agreed, 22.5% disagreed and 54.5% respondents strongly disagreed.13 In a study done in India, a different region, Madla, majority (four-fifths) of the respondents were able to correlate the transmission of malaria with mosquitoes, misconceptions existed among them. The types of malaria were not known to everyone. Only 39% were aware of the Indoor Residual Spray (IRS) and 41% understood the value of Long-Lasting Insecticidal Nets (LLIN). Around 71% of subjects surveyed were aware of the proper diagnostic tests for malaria. A total of 87% of the respondents knew about the MEDP staff working in their respective villages.14 In a cross-sectional study conducted on the assessment of Knowledge, Attitude and Practice on malaria prevention among 308 students of Hamelmalo Agricultural College, 302 participated yielding a response rate of 98.5%. Almost all respondents (99.3%) were aware of the existence of malaria as a disease. With regards to malaria symptoms, fever was the most frequently reported by participants accounting for 94.4% of responses followed by headache, 72% and chills 80.2%. 12% of the respondents reported diarrhea as a symptom of malaria. Out of those who knew malaria was a transmissible disease (n=255), 235 (92.5%) mentioned mosquito bite as a means of malaria transmission, however 11.3% stated by breathing, (1.96%) by housefly and (1.96%) by body contact. With regard to knowledge of mosquito breeding sites and biting time, 202 (66.8%) of the respondents mentioned stagnant water and waste material as mosquito breeding site, and 95 (31.5) stated mosquito breed in running water. With regard to knowledge on mosquito biting time, 293(97%) mentioned bites during the night and 3 (1%) during the day. With regards to available preventive measures, 94.7% stated that the use of mosquito bed nets is the most effective method to prevent malaria infection, 69.5% by using indoor residual spray, 92.4% by draining stagnant water, 76.8% by clearing vegetation. However, 28.5% and 21.5% mentioned IRS and clearing vegetation is not preventing malaria infection. Generally, from the study, 60% of the respondents were found to have fairly good knowledge of malaria transmission.15 In a cross sectional study conducted on the Knowledge and practice of methods of malaria prevention among nursing and midwifery students in Plateau State, it was discovered that majority of the respondents 146(95.4%) knew that malaria can be transmitted through the bite of a female Anopheles mosquito while 7(4.6%) stated that malaria can be transmitted by sleeping in the open. Most of the respondents 94.8% knew that sleeping under insecticide treated nets can prevent against mosquito bite. Knowledge about trimming of bushes 77.1%, use of insecticide spray 75.8% and draining of stagnant water 73.9% were also high. Overall knowledge of prevention was found to be good among 112(73.2%) of the studied students while 41(26.8%) of the respondents had poor knowledge.16 In a study on the knowledge and practice of malaria prevention and management among non-medical students of University of Nigeria Nsukka, a total of 800 consenting students participated in the study. Four hundred and thirty (54.5%) of the students were aged 21- 26 years. Five hundred and twenty-two (65.2%) of the respondents were female. More than half of the respondents 528 (66%) agreed that malaria is common in the tropical region. Almost half of the respondents 764 (95.5%) stated that mosquito breeds more during rainy season. Less than one-tenth of the respondents 43 (5.4%) reported that Plasmodium falciparum is the most common species that cause malaria. Less than one- fifth of the respondents 199(12.4%) understood the meaning of malaria prophylaxis.17 In a study conducted among members of a university in Kwara State, five hundred and eighteen undergraduate students and ninety-one staff (both academic and non-academic) of the university were selected for the study. On the respondents knowledge of the severity, causes and prevention of malaria, 218 (42.09%) understood it as a deadly disease, 280 (54.05%) as ordinary disease, while 20 (3.86%) of the students had no clear idea about the severity of malaria. Majority, 516 (99.62%), of the students agreed that malaria disease was caused by mosquito bite. On malaria vector identity, 222 (42.09%) of the students identified the female Anopheles mosquito as the vector of malaria, although larger percentages of students (44.59%) had no idea of the vector identity. Out of the 518 students sampled, 32.82% picked stagnant water, 27.03% water retaining containers and 38.19% plant/vegetation as vector habitat respectively. Majority of the students 83.78% responded that night was the prominent vector biting period. On the knowledge of symptoms of malaria among students, 71.81% ranked fever, 31.85% body pain and 29.53% headache as main symptoms of malaria. On the basis of source of information, majority of the respondents had various sources of information on the nature of vector, habitat, symptoms, prevention and treatment of the disease. 282(54.44%) students were enlightened by health professionals, 38.22% by friends, family and relatives, while 17.37% had their information from other sources.18 2.3 ATTITUDE OF STUDENTS TOWARDS THE USE OF IRS AS A MEANS TO CONTROL THE MALARIA VECTOR A study in Mewat Region in Haryana in India showed that despite having positive perception towards IRS, a large number of respondents in the study population did not apply it. In this regards 83% of the study population mentioned IRS as an effective preventive measure against malaria vector, but there were only 64% of the houses where all rooms have been sprayed as reported by the participants.19 In a study, conducted in Zambia to assess the knowledge, attitude and practice assessment of malaria interventions in rural areas, most participants (99%, 74/75) answered that they felt comfortable sleeping under a mosquito net, although 36% (27/75) reported that mosquito nets made them feel hot. Thirteen percent of caregivers (10/75) reported that IRS application took too much of their time and 31% (23/75) agreed with the statement that IRS does not prevent them from getting malaria.20 In another study conducted in Mandla on Assessing community knowledge, attitude and practices to strengthen communication strategy for Malaria Elimination Demonstration Project, the study revealed that Programme-supported preventive measures such as IRS and LLIN were known to only 39% of the respondents. It is worth mentioning here that IRS is usually not allowed in all the rooms of the house by the community due to the fear of its ill-effects. In addition to this, most of the IRS schedule is not pre-intimated to community members, thus it does not give adequate information to prepare for household Spraying programmes leading to poor acceptance. A small section of the respondents also mentioned about the misuse of LLIN.21 In another study conducted in an antenatal clinic in Ibadan Lagos State among 500 pregnant women, majority of the pregnant women had between good and fair knowledge of IRS. Less than 70% of the respondents were willing to allow IRS in their homes.22 In a study conducted in Nasarrawa state of Nigeria, after intensive education on IRS, Majority of respondents were male (79.7%) and married (82.6%), and their mean age was 36.4 ± 13.3 years. Coverage of IRS was 99.3%. However, only 82.6% of those who previously accepted IRS were willing to accept it in again. Factors independently associated with acceptability were perceived effectiveness of IRS and lower household cost of malaria prevention after IRS. 29 In a study on Infectivity rate of anopheles mosquito species and the community perception after indoor residual spraying programme in Awka and Environs, Anambra state. A large proportion of the study respondents having a positive perception towards IRS, who reported positive community perceptions when IRS or related prevention interventions were introduced. Majority of the respondents here, 70% indicated that IRS programme reduces malaria episodes. In this study, only a few had a negative perception that IRS causes skin allergies, sneezing and running nose and discolouring the walls. Additionally, this study also observed that despite many having positive perceptions towards IRS, others still had negative perceptions towards its use. These negative perceptions may be attributed to spraymen’s conducts, misinformation about the insecticide used and misunderstanding the function of IRS. Thus, although the majority of respondents had positive perceptions, a small proportion still had negative perceptions towards the use of IRS. 30 2.4 OTHER METHODS OF MALARIA VECTOR CONTROL USED BY THE STUDENTS In a descriptive cross sectional study conducted on the Knowledge, attitudes, and practices of the University students on malaria prevention in Kavango East, Namibia, it was discovered that a total of 98(41%) of the respondents used mosquito nets sometimes of which only 43(18%) always slept under it to prevent themselves from getting malaria, 15% always used insect repellant coils with about half of the respondents having a choice to use it sometimes. More than half of the respondents (51%) sometimes used anti mosquito spray in their rooms while 22% of them who use it always, 17% of the respondents indicated that they always cut and clear bushes around their houses and 43% of them cleared the bushes sometimes. The study also revealed that 41% of the respondents sometimes cleaned stagnant water near their houses or hostel and 23% of them did this always. From this study, the use of anti-mosquito sprays was indicated as the mostly used method to prevent malaria among university students.24 The earlier mentioned study showed consistency with one done in Ghana , where The malaria control practices of the people in the district was assessed and which showed that 177 (44%) uses IRS, 169 (42%) of the respondents uses mosquito sprays as a malaria preventive measure. The other malaria control practices of the respondents were mosquito repellents, local herb repellents and only 8 (2%) of the respondents employ the use of malaria chemoprophylaxis to prevent the transmission of malaria in their household. This shows that there is a positive relationship between the use of other malaria control practices of the people and the acceptability of IRS in the district (P