| ObjectivesThe present study aims to assess malaria prevention and treatment capacity after mass drug administration（MDA）with Artemisinin-Piperaquine（AP）in Grande Comore Island,Comoros,and to provide reference basis for future malaria elimination protocole to the Ministry of Health and the National Malaria Control Programme（NMCP）of the Comoros,and to the antimalarial team of Guangzhou University of Chinese Medicine.The specific objectives of the present research are:1.To investigate the impacts of two rounds of MDA with AP in Grande Comore Island in 2019 on the island’s malaria epidemic situation.2.To assess the level of knowledge of district health coordinators and village malaria workers toward malaria and MDA with AP;to analyse the relationship between the level of knowledge of village malaria workers and the malaria prevalence of their village.3.To know the level of knowledge of the target population in Grande Comore Island toward basic knowledge of malaria and MDA with AP,as well as their malaria prevention practice;to analyse the relationship between the level of knowledge of the population and the malaria incidence in the target villages;and finally,to explore the level of knowledge of population with different education levels.Methods1.Baseline data of Grande Comore Island were collected,including geography,demography,climate,characteristics of local households,malaria transmission vectors,malaria prevention and treatment measures,history of use of antimalarial drugs,structure and human resources of the NMCP,background information on health facilities and health workers,and the number of malaria cases from health institutions.Select 2 villages with the highest malaria incidence from east,south,west,north,and center of the island.A total of 10 villages of Grande Comore Island were selected as sentinel sites based on their geographical location.Data related to the 2019 MDA with AP including MDA coverage rates,parasite carriage rates before and after MDA,and malaria confirmed cases from health institutions were collected and summarized.Changes in parasite carriage rates and number of malaria cases before and after MDA were compared in order to know the effects of the MDA on the control of malaria epidemic of Grande Comore Island.2.Study planning and pre-designed questionnaires on malaria and MDA with AP were drafted for knowledge survey of district health coordinators and village malaria workers.When designing the questionnaires for knowledge survey,relevant published scientific articles were taken as references,and the education level and medical educational background of district health coordinators and village malaria workers were taken into account.Therefore,the level of difficulty of questionnaire for district health coordinators was different to that of the questionnaire for village malaria workers.The level of difficulty of the questions was confirmed with the technical trainers of the NMCP.A one-to-one oral interview with each of the 9 district health coordinators and 40 village malaria workers was carried out,relevant data were collected through questionnaire,then questionnaires were sorted out.The content of the questionnaire for district health coordinator included written consent,the age,the highest education level,the marital status,the conditions for malaria pre-elimination,the objective of MDA and other questions related to malaria.The content of the questionnaire for village malaria workers included written consent,the highest education level,the marital status,the transmission characteristic of malaria,malaria vector,mode of transmission of malaria,malaria symptoms,malaria diagnosis method,as well as MDA with AP.Only valid questionnaires were kept for analysis,each questionnaire was corrected and points were given,10 points for correct answers on all 10 questions.The questionnaire surveys were carried out by the author and the malaria focal point of Grande Comore Island.Data were entered by data entry agents using SPSS statistical software 23.0 and Microsoft Excel,the author personally proceeded for data checking.Invalid questionnaires were not taken into account in the analysis.Descriptive statistics was used to analyse socio-demographic data,average and standard deviation（x±s）were used for quantitative data,and percentage was used for qualitative data.Based on the local malaria epidemiology and the malaria incidence on the MDA year,village malaria incidence was used as standard unit,and the 10 sentinel sites were divided into low level endemicity（village with malaria incidence<5%）,intermediate level of endemicity（village with malaria incidence 5-20%）and high level of endemicity（village with malaria incidence>20%）.Based on the points obtained,the levels of knowledge were divided into low level of knowledge（0-4 points）,intermediate level of knowledge（5-7 points）and high level of knowledge（8-10 points）.Finally,the points obtained by the district health coordinators and village malaria workers were calculated,and the relationship between the level of knowledge of village malaria workers and their village malaria incidence was analyzed.3.A survey planning and pre-designed questionnaire on knowledge,attitude and practice（KAP）of Grande Comore population toward basic knowledge of malaria and MDA with AP were drafted and designed.Published scientific KAP articles were reviewed as references for the questionnaire design.A meeting was held with the Director of the NMCP,healthcare backbones,district health coordinators and village malaria workers from the 10 sentinel sites of Grande Comore Island to introduce the objective of the community-based KAP survey,the method and the implementation procedure.The level of difficulty of the questions was confirmed during the meeting.A training was held with the district health coordinators and village malaria workers.The training contents included the objectives of the communitybased KAP survey,how to greet heads of households,how to fill in correctly the questionnaire.Then,the dates of the KAP field survey were confirmed and the list of investigators was finalized.Investigators were trained village malaria workers.Investigators went to the 10 villages,door to door,to visit each household,and proceed to one-to-one oral interview of the heads of households.After the survey,questionnaires were collected and sorted out.Data in the questionnaires included the full name and age of heads of households,the education level,the marital status,questions about malaria vector,symptoms,diagnosis method,the treatment regimen and dosage of AP during MDA,the measure taken by the head of household within 24 hours of onset of malaria symptoms,and mosquito prevention measures.Data was entered by data entry agent using CSPro 7.2,two data quality controllers proceeded to data checking,then the author and the statistician of the local Department of Health proceeded to manual double verification.When sorting out data,only questionnaire numbers and answers were taken into consideration.Correctness of answers was verified,points were given to each questionnaire,10 points for correct answers on all 10 questions.After entry,data were imported using Microsoft Excel.Invalid questionnaires were not taken into account in the analysis.Data entry and analysis were performed using SPSS statistical software 23.0.Descriptive statistics was used to analyse the socio-demographic data,mean and standard deviation（x±s）were used for quantitative data,and percentage was used for qualitative data.For two sets of quantitative data meeting the t-test conditions,the two independent samples t-test was used;if t-test conditions were not met,the two independent samples rank sum test was used.For qualitative data meeting the Chi-square test conditions.Chi-square test was used;if Chi-square test conditions were not met,Fisher exact test was used.The education level and score differences between males and females were compared.The relationship between the level of knowledge of participants with their village malaria incidence was analysed.And finally,the level of knowledge of head of households toward malaria and MDA was compared in different category of education levels.Results1.The two rounds of MDA with AP conducted in Grande Comore Island in 2019 has rapidly controlled malaria on the island.Before MDA,the average parasite carriage rate of the 10 sentinel sites was 14.1%.After the 1st round of MDA,the 2nd round of MDA,and 1 year after the last round of MDA,the average parasite carriage rates were 1.0%.0.5%and 0.5%,respectively,a reduction of 92.8%,96.6%and 96.9%,respectively,compared to data before MDA.The average gametocyte positive rate of the 10 sentinel sites went from 3.4%before the 1st round of MDA to 0.5%after the last round of MDA,a reduction of 96.9%.2.The average total point of the 9 district health coordinators on knowledge about malaria and MDA was 5.6（full points was 10 points）,an intermediate level of knowledge.The average total point of the 40 village malaria workers on knowledge about malaria and MDA was 8.41,a high level of knowledge.Village malaria workers from both intermediate and high level malaria endemicity villages have high level of knowledge.3.A total of 1,3 68 heads of households were interviewed in the 10 villages,among which 1,027（75.1%）were females and 341（24.9%）were males.The average age of the participants was 43.97 years old,76.5%were married,10.4%were single,42.5%had no prior education,12.9%finished higher education,and 37.9%were unemployed.Among the 1,027 females,45.9%had no prior education;and among the 341 males,32.3%had no prior education.The percentage of males finishing higher education（18.5%）was higher than the percentage of females finishing higher education（11.0%）,and the difference in education level between males and females was statistically significant（P<0.05）.81.4%of participants knew that malaria is a transmissible disease,6.7%thought malaria was not transmissible;77.6%of participants knew that malaria is transmitted by mosquito.However,some participants replied that malaria is transmitted by parasite（9.1%）,virus（1.5%）or bacteria（0.9%）.Some heads of households（10.9%）did not know the answer.46.2%of participants knew that malaria is transmitted from the malaria patient or parasite carrier to another human being through a mosquito bite,32.2%replied that malaria is directly transmitted by the mosquito to a human.70.8%of participants knew that fever is one of the frequent symptoms of malaria.84.4%of participants knew that malaria is diagnosed through blood test.However,1.4%thought that malaria is diagnosed through urine test.Only 40.8%of interviewed heads of households knew that the name of the antimalarial drug used for MDA in the Comoros was Artequick?（AP）,45.5%did not know the name of the antimalarial drug and 13.7%replied that the name of the antimalarial drug was Coartem（Artemether-Lumefantrine,AL）,the first-line drug for the treatment of uncomplicated falciparum malaria in the Comoros.62.1%of participants knew that the color of the Artequick? tablets was green.65.1%knew that babies less than 3 months old do not participate to MDA,5.2%replied that babies less than 3 months old can participate to MDA.46.5%knew that the treatment period with Artequick? during MDA is 2 days.72.7%of heads of households knew that one cannot share its own treatment drug with other family members,but 11.8%replied the opposite,that one’s drug can be shared with other family members.In the present study,although the number of female participants（75.1%）is significantly higher than male participants（24.9%）,the knowledge level difference between men and women toward malaria and MDA is not big,and is not statistically significant（P>0.05）.81.4%of participants slept under bed nets the night before the KAP survey,10.7%didn’t.24 hours within onset of malaria symptoms,65.1%of participants choose to go to health institutions seeking treatment,12.9%went directly to the drugstore by themselves to buy antipyretic drug,12.8%chose traditional treatment,and 9.2%wouldn’t take any action.The average total point of all participants on knowledge on malaria and MDA is 6.5.The average total point of participants from intermediate level malaria endemicity villages is 6.7,higher than the average total point of all participants;and the average total point of participants from high level malaria endemicity villages is 5.9.lower than the average total point of all participants.The level of knowledge of population from villages with middle level of malaria endemicity was higher than the level of knowledge of population from village with high level of endemicity,and among the category of head of households with low level of knowledge,the number of individuals with no prior education was the highest.Conclusion1.Two rounds of MDA with AP effectively reduced the number of malaria confirmed cases in health institutions and parasite carriage rate in Grande Comore Island.2.The level of knowledge of district health coordinators on malaria and MDA with AP was intermediate and the level of knowledge of village malaria workers was high.The levels of knowledge of village malaria workers from villages with high and intermediate level of malaria endemicity were high,village malaria incidence had no direct relation with the level of knowledge of village malaria workers.3.The level of knowledge of population in villages with intermediate level of malaria endemicity was slightly higher than that of those from villages with high level of malaria endemicity.In other words,the higher the knowledge of the population on malaria and MDA,the lower the village malaria incidence.Although the level of knowledge of the population of Grande Comore Island on basic knowledge of malaria and MDA with AP was relatively high,there were still misconceptions and misunderstandings about malaria mode of transmission,method of diagnosis,dosage of the MDA drug and other questions among the local residents.No prior education could be a predictor of low level of knowledge of head of households.4.If a high MDA coverage rate and a sound malaria monitoring and surveillance can be ensured,MDA can control malaria on the island of Grande Comore.The measure of malaria control by source eradication might have strengthen the knowledge of the local antimalarial team.Antimalarial workers are the key pillars for a country to go toward malaria elimination,and district health coordinators and village malaria workers are the key personnel for the Comoros to go toward malaria elimination.On the basis of improving the local malaria prevention and control system and strengthening the capacity building,the project of the malaria control by source eradication should however consider to increase the number of local middle and high level technical staff,to strengthen training of district health coordinators and village malaria workers to improve their knowledge and work capacity in the fight against malaria.On the other hand,the level of knowledge of the population on malaria and their malaria prevention practice are very important and could have impacts on malaria elimination.Therefore,the Comoros government should attach greater importance to the increase of the level of knowledge of the population in malaria and malaria prevention,and promptly correct the wrong malaria prevention behavior and practice in order to increase the participation and compliance of the population in malaria elimination activities.The project of malaria control through source eradication should strengthen the awareness interventions on malaria prevention and control,so to fill in the gap in health knowledge of the population from informal education. |
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