Knowledge, attitudes, and practices concerning malaria in pregnancy: results from a qualitative study in Madang, Papua New Guinea

Background

Malaria is the leading cause of illness and death in Papua New Guinea (PNG). Infection during pregnancy with falciparum or vivax malaria, as occurs in PNG, has health implications for mother and child, causing complications such as maternal anemia, low birth weight and miscarriage. This article explores knowledge, attitudes and practices concerning malaria during pregnancy and it’s prevention in Madang, PNG, a high prevalence area.

Methods

As part of a qualitative study in Madang, exploring MiP, participatory techniques (free-listing and sorting) were conducted along with focus group discussions, in-depth interviews (with pregnant women, health staff and other community members) and observations in the local community and health facilities.

Results

The main themes explored were attitudes towards and knowledge of MiP, its risks, and prevention. Although there was a general awareness of the term “malaria”, it was often conflated with general sickness or with pregnancy-related symptoms. Moreover, many preventive methods for MiP were related to practices of general healthy living. Indeed, varied messages from health staff about the risks of MiP were observed. In addition to ideas about the seriousness and risk of MiP, other factors influenced the uptake of interventions: availability and perceived comfort of sleeping under insecticide-treated mosquito nets were important determinants of usage, and women’s heavy workload influenced Chloroquine adherence.

Conclusion

The non-specific symptoms of MiP and its resultant conflation with symptoms of pregnancy that are perceived as normal have implications for MiP prevention and control. However, in Madang, PNG, this was compounded by the inadequacy of health staff’s message about MiP.

Medicinal chemistry optimization of antiplasmodial imidazopyridazine hits from high throughput screening of a SoftFocus kinase library: part 1

A novel class of imidazopyridazines identified from whole cell screening of a SoftFocus kinase library was synthesized and evaluated for antiplasmodial activity against K1 (multidrug resistant strain) and NF54 (sensitive strain). Structure-activity relationship studies led to the identification of highly potent compounds against both strains. Compound 35 was highly active (IC50: K1 = 6.3 nM, NF54 = 7.3 nM) and comparable in potency to artesunate, and 35 exhibited 98% activity in the in vivo P. berghei mouse model (4-day test by Peters) at 4 × 50 mg/kg po. Compound 35 was also assessed against P. falciparum in the in vivo SCID mouse model where the efficacy was found to be more consistent with the in vitro activity. Furthermore, 35 displayed high (78%) rat oral bioavailability with good oral exposure and plasma half-life. Mice exposure at the same dose was 10-fold lower than in rat, suggesting lower oral absorption and/or higher metabolic clearance in mice.

Atypical brain response to novelty in rural African children with a history of severe falciparum malaria

Plasmodium falciparum is the most common parasitic infection of the central nervous system causing neuro-cognitive deficits in 5-26% of paediatric cases. The burden cannot be reliably estimated because of lack of sensitive, culture-fair and robust assessments in rural settings. Auditory and visual brain event related potentials (ERPs) are used to compare novelty processing in children exposed to severe malaria with community controls. Fifty children previously admitted and discharged from Kilifi District Hospital with severe falciparum malaria were selected and compared with 77 unexposed age matched children. The results showed that up to 14% of children exposed to severe malaria had significantly different responses to novelty compared to unexposed children. Children exposed to severe malaria had smaller P3a amplitudes to novelty in both auditory [F (3, 119)=4.545, p=0.005] and visual [F (3, 119)=6.708, p<0.001] paradigms compared to unexposed children. In the auditory domain the differences in processing of novelty were not related to early component processing. The percentage of children with severe malaria showing impaired performance using ERPs is within the range previously reported using neuropsychological tests. The overall pattern suggests that severe malaria affects prefrontal and temporal cortices normally activated by stimulus novelty.

Impact of transmission intensity on the accuracy of genotyping to distinguish recrudescence from new infection in antimalarial clinical trials

Antimalarial clinical trials use genotyping techniques to distinguish new infection from recrudescence. In areas of high transmission, the accuracy of genotyping may be compromised due to the high number of infecting parasite strains. We compared the accuracies of genotyping methods, using up to six genotyping markers, to assign outcomes for two large antimalarial trials performed in areas of Africa with different transmission intensities. We then estimated the probability of genotyping misclassification and its effect on trial results. At a moderate-transmission site, three genotyping markers were sufficient to generate accurate estimates of treatment failure. At a high-transmission site, even with six markers, estimates of treatment failure were 20% for amodiaquine plus artesunate and 17% for artemether-lumefantrine, regimens expected to be highly efficacious. Of the observed treatment failures for these two regimens, we estimated that at least 45% and 35%, respectively, were new infections misclassified as recrudescences. Increasing the number of genotyping markers improved the ability to distinguish new infection from recrudescence at a moderate-transmission site, but using six markers appeared inadequate at a high-transmission site. Genotyping-adjusted estimates of treatment failure from high-transmission sites may represent substantial overestimates of the true risk of treatment failure.

Community response to intermittent preventive treatment delivered to infants (IPTi) through the EPI system in Manhiça, Mozambique

OBJECTIVE

To describe attitudes to the expanded programme on immunization (EPI) and intermittent preventive treatment in infants (IPTi), and perceptions of the relationship between them. In particular, whether the introduction of IPTi negatively affects community attitudes to, or use of, EPI; or, conversely, whether and if so how, the concurrent delivery of IPTi and immunization influences perceptions of IPTi.

METHODS

Anthropological study carried out in the context of a trial of IPTi with sulphadoxine-pyrimethamine delivered alongside routine EPI vaccinations. We used open in-depth interviews, semi-structured interviews and participant observation, conducted in both community and clinic settings.

RESULTS

IPTi was generally acceptable, in spite of initial resistance. Perceived negative aspects of IPTi did not affect perceptions of EPI, and IPTi was not misinterpreted as immunization against malaria, leading to a reduction of other preventive measures or delay in treatment seeking. Initial resistance was related more to the trial than to IPTi per se, but both rejection and acceptance were embedded in a complex constellation of local and wider contextual factors.

CONCLUSIONS

IPTi delivered together with EPI was generally accepted after initial rejection. The factors that led to this rejection were largely local and trial related, but they did resonate with much wider cultural themes (rumours about research and health interventions, gender inequality and health-related decision making). The prior acceptance and routine administration of EPI played a key role in the acceptance of IPTi in this community. However, more studies, in different social and cultural settings and using different drugs and regimens, are needed before generalizations can be made. Although trial settings are different from actual implementation, it is necessary to study acceptability before implementation in order to anticipate problems and design information campaigns to ensure maximum community acceptance.

The effect ofPlasmodium falciparumon cognition: a systematic review

OBJECTIVE

Systematic review to investigate the relationship between Plasmodium falciparum infection and cognitive function.

METHOD

We searched MEDLINE, EMBASE and PsycINFO, and hand-searched journals and PhD theses. The inclusion criteria were (1) use of standardized tests for the specific populations and/or appropriate controls; (2) clear differentiation between children and adults. Eighteen studies were eligible, of which three gave information on all cognitive domains considered in the review.

RESULTS

Deficits in attention, memory, visuo-spatial skills, language and executive functions may occur after malaria infection. These deficits are not only caused by cerebral falciparum malaria, but also appear to occur in less severe infections. P. falciparum seems to affect the brain globally, not in a localised fashion. Outcome depends on both biological and social risk factors.

CONCLUSION

Future research should seek to establish the extent of these cognitive deficits using culturally appropriate techniques and well-defined criteria of disease.

A randomized, double-blind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children

A double-blind, placebo-controlled trial of nine months duration was carried out to investigate the impact of malaria and its prevention on the educational attainment of school children in a malaria-endemic area in southern Sri Lanka where both Plasmodium falciparum and P. vivax infections are prevalent. A total of 587 children attending grades 1-5 in four schools and resident in the area were randomly allocated to chloroquine (n = 295) and placebo (n = 292) arms. Language and mathematics scores of end-of-term school examinations for 1998 and 1999 and number of days absent and reasons for absenteeism during seven months pre-intervention and nine months of the intervention were recorded. The results indicate that there were no differences in language (95% confidence interval [CI] = 48.44-53.78 in chloroquine group and 50.43-55.81 in placebo group) and mathematics (95% CI = 49.24-54.38 in chloroquine group and 51.12-56.38 in placebo group) scores between the two groups prior to the intervention. During the intervention, the malaria incidence rate decreased by 55% (95% CI = 49-61%) and school absenteeism due to malaria was reduced by 62.5% (95% CI = 57-68%) in children who received chloroquine compared with the placebo group. Post-intervention, children who received chloroquine scored approximately 26% higher in both language (95% CI = 21-31%) and mathematics (95% CI = 23-33%) than children who received placebo. In a multivariate model, educational attainment was significantly associated with taking chloroquine prophylaxis and absenteeism due to malaria (P < 0.001 for both) but not due to health causes other than malaria or non-health causes. Language scores were associated with number of malaria attacks (P < 0.022). Educational attainment was significantly better among children whose compliance to chloroquine prophylaxis was higher (P < 0.001). The data suggest that malarial attacks have an adverse impact on the educational attainment of the school child and prevention of these attacks significantly improves educational attainment of children living in malaria-endemic areas.

Use of intermittent preventive treatment for malaria in pregnancy in a rural area of western Kenya with high coverage of insecticide-treated bed nets

Kenya established intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) for malaria in pregnancy as national policy in 1998. We assessed the coverage of IPT among women who had recently delivered in a rural area of western Kenya with perennial malaria transmission and high coverage with insecticide treated nets (ITNs) through a cross-sectional, community-based survey in December 2002. Antenatal clinic (ANC) attendance was high (89.9% of the 635 participating women); 77.5% of attendees visited an ANC before the third trimester and 91.9% made more than one visit. Delivery of SP by the ANC was reported by 19.1% of all women but only 6.8% reported receiving more than one dose. Given the high rate of use of ANC services, if SP were given at each visit after the first trimester, the potential coverage of IPT (two doses of SP) would be 80.3% in this study population. ITNs were used by 82.4% of women during pregnancy, and almost all mothers (98.5%) who slept under an ITN shared the nets with their newborns after delivery. Women who thought malaria in pregnancy caused foetal problems were more likely to have used an ITN (adjusted odds ratio [AOR] 1.6, 95% confidence interval [CI] 1.0-2.4), and to have visited ANC more than once (AOR 2.4, 95% CI 1.2-4.7) compared to women who thought malaria in pregnancy was either not a problem or caused problems for the mother only. These findings illustrate the need for improved IPT coverage in this rural area. Identification and removal of the barriers to provision of IPT during ANC visits can help to increase coverage. In this area of Kenya, health messages stressing that foetal complications of malaria in pregnancy may occur in the absence of maternal illness may improve the demand for IPT.

Malaria infection among pregnant women attending antenatal clinics in six Rwandan districts

OBJECTIVES

The aim of the study was to assess the knowledge, attitude and practices of pregnant women towards malaria and their association with malaria morbidity.

METHODS

Cross-sectional malaria survey of 1432 pregnant women attending six health centres, each of them situated in a specific health district in Rwanda from September to October 2002.

RESULTS

The overall prevalence of malaria infection was 13.6% and all infections but two were caused by Plasmodium falciparum. The six health districts were significantly different in terms of malaria prevalence, which varied between 11.5% and 15.4% in four and was <5% in the other two districts. The prevalence of anaemia and splenomegaly mirrored that of malaria infection. In three districts, the prevalence of infection was significantly higher in primigravidae than in secundigravidae and multigravidae (P = 0.01), while in two others it did not vary with parity. Bed net use was low - only 13.1% of the women had at least one bed net at home and 8.3% of them slept under it - and significantly different between districts. Most women knew that malaria might have serious consequences for their pregnancy and that insecticide-treated bed nets are useful for malaria prevention. However, the bed net market price [1525 Rwandan Francs (RFr), approximately 1.6] was much higher than that considered as affordable and acceptable (389 RFr, approximately 0.3).

CONCLUSION

Malaria in pregnancy is a major problem in Rwanda, even in the districts of low transmission. Bed net use among pregnant women is low. The option of providing free insecticide-treated bed nets to pregnant women should be explored and possibly implemented; it could rapidly increase bed net use and earlier attendance to antenatal clinics with clear benefits for the women's health.

Efficacy and effectiveness of the combination of sulfadoxine/pyrimethamine and a 3-day course of artesunate for the treatment of uncomplicated falciparum malaria in a refugee settlement in Zambia

In the Maheba Refugee Settlement, in the clinics supported by Medecins Sans Frontieres, all children aged up to 5 years with a confirmed diagnosis of uncomplicated falciparum malaria are treated with the combination of sulfadoxine/pyrimethamine (SP) and artesunate (AS). We compared the treatment's efficacy and effectiveness. Patients were randomized in order to receive the treatment supervised (efficacy) or unsupervised (effectiveness). Therapeutic response was determined after 28 days of follow up. The difference between recrudescence and re-infection was ascertained by polymerase chain reaction (PCR). We also assessed genetic markers associated to SP resistance (dhfr and dhps). Eighty-five patients received treatment under supervision and 84 received it unsupervised. On day 28, and after PCR adjustment, efficacy was found to be 83.5% (95% CI: 74.1-90.5), and effectiveness 63.4% (95% CI: 52.6-73.3) (P < 0.01). Point mutations on dhfr (108) and dhps (437) were found for 92.0% and 44.2% respectively of the PCR samples analysed. The significant difference in therapeutic response after supervised and unsupervised treatment intake can only be explained by insufficient patient adherence. When implementing new malaria treatment policies, serious investment in ensuring patient adherence is essential to ascertain the effectiveness of the new treatment schedules.

Developmental impairments following severe falciparum malaria in children

OBJECTIVE

Neurological deficits are reported in children after cerebral malaria (CM) but little is known about the prevalence and characteristics of persisting neurocognitive consequences. The prevalence of developmental impairments following other complications of falciparum malaria, such as multiple, prolonged or focal seizures, is not known. Thus, our objective was to investigate the long-term developmental outcome of CM and malaria with complicated seizures (M/S).

METHODS

We followed up a cohort of children previously exposed to CM or M/S and children unexposed to either condition. All children between 6 and 9 years of age, exposed to CM, and an equal number of children exposed to M/S were identified from databases of hospital admissions from 1991 to 1998. The unexposed group was randomly selected from a census database. The children's performance was measured using assessments of cognition, motor, speech and language, hearing and vision. A parental questionnaire was used to identify children with epilepsy.

RESULTS

CM group scores were significantly lower than unexposed group scores on the assessments of higher level language (adjusted mean difference -1.63, 95% CI: -2.99 to -0.27), vocabulary (-0.02, 95% CI: -0.04 to -0.01), pragmatics (OR 2.81, 95% CI: 1.04-7.6) and non-verbal functioning (-0.33, 95% CI: -0.61 to -0.06). The areas of significantly reduced functioning for the M/S group were concentrated on phonology (OR 2.74, 95% CI: 1.26-5.95), pragmatics (OR 3.23, 95% CI: 1.2-8.71) and behaviour (OR 1.8, 95% CI: 1.0-3.23). The performance of the active epilepsy group was significantly poorer than that of the group without epilepsy on the tests of comprehension, syntax, pragmatics, word finding, memory, attention, behaviour and motor skills.

CONCLUSIONS

CM and M/S are associated with developmental impairments. If these impairments persist, this may have implications for least 250,000 children in Sub-Saharan Africa each year. Active epilepsy significantly increases the risk of cognitive and behavioural problems in children with a history of severe malaria.

Implementation of intermittent preventive treatment with sulphadoxine-pyrimethamine for control of malaria in pregnancy in Kisumu, western Kenya

OBJECTIVE

In 1998, the Kenyan Ministry of Health introduced intermittent preventive treatment (IPT) with sulphadoxine-pyrimethamine (SP), one treatment dose in the second trimester (16-27 weeks) and one treatment dose between 28 and 34 weeks of gestational age, for the control of malaria in pregnancy. We evaluated the coverage and determinants of receipt of IPT after its introduction in the Provincial Hospital in Kisumu, western Kenya.

METHODS

Information on the use of IPT in pregnancy was collected from women who attended the antenatal clinic (ANC) and delivered in the same hospital. In exit interviews, we assessed patterns of IPT use in the ANC.

RESULTS

Of 1498 women who delivered between June 1999 and June 2000, 23.7%, 43.4% and 32.9% received > or =2, 1 or no dose of SP, respectively. Late first ANC attendance was the most important factor contributing to incomplete IPT; 45% of the women started attending ANC in the third trimester. More women received at least one tetanus toxoid immunization than at least one dose of IPT (94%vs. 67%, P < 0.05). In exit interviews, 74% correctly associated IPT with treatment of malaria; however, knowledge on the need for the second dose was poor. Three per cent of the administrations were given despite contraindications. The agreement between gestational age by date of last menstrual period and by palpation was low (kappa = 0.1).

CONCLUSIONS

Education of pregnant women and ANC staff to increase earlier attendance for ANC has the potential to substantially increase the proportion of women receiving two doses of IPT with SP.

Glutathione--functions and metabolism in the malarial parasite Plasmodium falciparum

When present as a trophozoite in human erythrocytes, the malarial parasite Plasmodium falciparum exhibits an intense glutathione metabolism. Glutathione plays a role not only in antioxidative defense and in maintaining the reducing environment of the cytosol. Many of the known glutathione-dependent processes are directly related to the specific lifestyle of the parasite. Reduced glutathione (GSH) supports rapid cell growth by providing electrons for deoxyribonucleotide synthesis and it takes part in detoxifying heme, a product of hemoglobin digestion. Free radicals generated in the parasite can be scavenged in reaction sequences involving the thiyl radical GS* as well as the thiolate GS-. As a substrate of glutathione S-transferase, glutathione is conjugated to non-degradable compounds including antimalarial drugs. Furthermore, it is the coenzyme of the glyoxalase system which detoxifies methylglyoxal, a byproduct of the intense glycolysis taking place in the trophozoite. Proteins involved in GSH-dependent processes include glutathione reductase, glutaredoxins, glyoxalase I and II, glutathione S-transferases, and thioredoxins. These proteins, as well as the ATP-dependent enzymes of glutathione synthesis, are studied as factors in the pathophysiology of malaria but also as potential drug targets. Methylene blue, an inhibitor of the structurally known P. falciparum glutathione reductase, appears to be a promising antimalarial medication when given in combination with chloroquine.

Psychiatric complications of malaria: a case report

This article reviews the psychiatric complications of malaria. A case of malaria infection is described. The diagnoses, treatment, and neuropsychiatric complications of acute and chronic malaria infection are discussed. The treatment of malaria and its complications are summarized.

Pharmacokinetics and pharmacodynamics of intravenous artesunate in severe falciparum malaria

To provide novel data relating to the dispositions, effects, and toxicities of the artemisinin derivatives in severe malaria, we studied 30 Vietnamese adults with slide-positive falciparum malaria treated with intravenous artesunate. Twelve patients with complications (severe; group 1) and 8 patients without complications but requiring parenteral therapy (moderately severe; group 2) received 120 mg of artesunate by injection, and 10 patients with moderately severe complications (group 3) were given 240 mg by infusion. Serial concentrations of artesunate and its active metabolite dihydroartemisinin in plasma were measured by high-performance liquid chromatography. The time to 50% parasite clearance (PCT(50)) was determined from serial parasite densities. Full clinical (including neurological) assessments were performed at least daily. In noncompartmental pharmacokinetic analyses, group mean artesunate half-lives (t(1/2)) were short (range, 2.3 to 4.3 min). The dihydroartemisinin t(1/2) (range, 40 to 64 min), clearance (range, 0.73 to 1.01 liters/h/kg), and volume of distribution (range, 0.77 to 1.01 liters/kg) were also similar both across the three patient groups (P > 0.1) and to previously reported values for patients with uncomplicated malaria. Parasite clearance was prompt (group median PCT(50) range 6 to 9 h) and clinical recovery was complete under all three regimens. These data indicate that the pharmacokinetics of artesunate and dihydroartemisinin are not influenced by the severity of malaria. Since the pharmacokinetic parameters for both artesunate and dihydroartemisinin were similar regardless of whether injection or infusion was used, artesunate can be considered a prodrug that is converted stoichiometrically to dhydroartemisinin. Conventional doses of artesunate are safe and effective when given to patients with complications of falciparum malaria.

The prime role of plasma membrane cholesterol in the pathogenesis of immune evasion and clinical manifestations of falciparum malaria

The pathogenesis of falciparum malaria, with its immune evasion, mechanism of immune suppression and immunological inertia, the cause of its preferential incidence in children and pregnant mothers, and the pathological basis of clinical manifestations, are discussed from biochemical, biophysical and immunological perspectives. Sequestration and recrudescence are highlighted as the evolved means by which malaria parasites survive. These discussions are based on a novel hypothesis that changes in the lipid matrix fluidity of plasma membrane, through alterations of cholesterol and phospholipid content and variation in body temperature, significantly affect the membrane functions of cells. The pathogenesis of aggressive behavior in cerebral malaria is postulated to be different from that of coma, and complicated pregnancy in malaria is also discussed as a multifactorial condition wherein hypocholesterolemia, resulting from increased membrane biogenesis of multiplying parasites, is the common underlying factor.

Delayed neuropsychiatric effects of malaria in Ghana

This study investigated the long-term emotional and cognitive effects of malaria infection in a sample of community resident nonmigratory Ghanaian adults, comparing 142 individuals with a documented history of clinical falciparum malaria and 30 controls without a lifetime medical diagnosis of malaria. Results were based on self-report inventory and interview-based approaches to assessment of emotional status as well as individual administration of the Mini-Mental State Examination. Our findings indicated the presence of an enduring, albeit subclinical, mixed anxiety-depression syndrome after medical recovery from falciparum malaria. There were, however, no significant neurocognitive deficits associated with malaria status on the objective screening instrument, nor were there reports of subjective attention, concentration, memory, or other cognitive complaints by self-report. Malaria may be a risk factor for psychiatric morbidity. We therefore recommend a search for effective malaria prevention and intervention strategies to avert the more serious clinical manifestations of mental disorder likely to evolve in this imminently lethal infectious disease.

Deficits in delayed memory following cerebral malaria: a case study

Cerebral malaria is a common disease, but there have not been any reports or investigations of long-term neurological or neuropsychological outcome. We present a case in which severe deficits in delayed memory and naming ability are observed 10 years after the patient contracted cerebral malaria. Neuropsychological testing and medical imaging are both consistent with temporal lobe/hippocampal dysfunction, which corroborates earlier animal research that cerebral malaria is particularly likely to lead to interrupted blood circulation in this area.

Perceptions of symptoms of severe childhood malaria among Mijikenda and Luo residents of coastal Kenya

Effective community based malaria control programmes require an understanding of current perceptions of malaria as a disease and its severe manifestations. Quantitative and qualitative surveys of mothers on the Kenyan Coast suggest that fever is conceptualised in biomedical terms whereas the aetiology of severe malaria is perceived to be of more complex cultural origin. This is reflected in the treatments sought for convulsions. The results are discussed in the context of ethnographic factors. To be effective, future health information programmes must take cultural beliefs into account.

Malaria and childbearing women in Malawi: knowledge, attitudes and practices

Information on women's use of antenatal clinic (ANC) service, including malaria prevention and treatment during pregnancy, was collected during a national malaria knowledge, attitudes, and practices survey in Malawi. Among 1531 households, 809 (53%) included a woman who had carried a pregnancy past the second trimester within the past 5 years. Of these, 756 (93%) women reported at least one ANC visit during pregnancy (median = 4); 336 (42%) attended 5 or more times. Approximately half (51%) reported delivering in a hospital; 5% delivered in a clinic; 13% delivered at home with a trained birth attendant; and 28% delivered at home with only family attending. Women at increased risk for delivery complications (e.g. primigravidas and grand multigravidas) were no more likely to attend ANC or deliver in hospital than women without increased risk. The woman's level of education was the only significant predictor of initiating ANC care, continued ANC attendance, and delivery in hospital. In a setting where 43% of women pregnant within the past 5 years had received no formal education and 70% had completed less than 5 years, this survey identified a critical need for targeting health messages towards poorly educated women to ensure proper utilization of antenatal care services, including coverage with malaria prevention throughout pregnancy.

Treatment of malaria fever episodes among children in Malawi: results of a KAP survey

Caretakers of children (< 10 years of age) were questioned about management of pediatric malarial fever episodes in a nation-wide knowledge, attitudes, and practices survey conducted in Malawi. A total of 1,531 households in 30 randomly selected clusters of 51 households each were sampled and interviewed. Overall 557 caretakers reported a fever in their child in the previous 2 weeks; 43%-judged the illness as severe. Fifty-two percent of caretakers brought their febrile children to clinic. Clinic attendance was positively correlated with young age of the child (< 4 years), severe illness, and higher socioeconomic status. Seventy-four percent of clinic attenders gave their child an antimalarial; in contrast, only 42% of those not attending clinic gave an antimalarial. Optimal therapy (administration of an antimalarial promptly and at the proper dosage) was received by only 7% of febrile children. Children taken to clinic were twice as likely to receive optimal therapy as were non-attenders. Identification of critical points in the optimal therapy algorithm and characteristics of caretakers linked with sub-optimal therapy may help malaria control programs target specific groups and health education messages to improve treatment of malaria fever episodes.

Illness perception: social cost and coping-strategies of malaria cases

This paper looks at illness perceptions and lay management of malaria in the context of new settlement. While the new settlement places unique pressures on the population there are several trends observed that have relevance for program planning and implementation.

[Simple methods of chloroquine determination in urine and their adaptation in the field]

Field malaria studies require often the on site detection of chloroquine in urine for monitoring chemoprophylaxis and treatment compliance, investigating drug-use patterns and screening prospective subjects for in vitro and in vivo chemosensitivity tests. The field adapted methods are described, analytical characteristics are compared and different approaches to field adapted assay of chloroquine are discussed.