Determining the Impact of Scaling up Mass Testing, Treatment and Tracking on Malaria Prevalence Among Children in the Pakro Sub District of Ghana

Background Malaria continues to pose a serious burden to the local populations in sub-Sahara Africa. Several efforts have been made to scale up interventions that work such as preventing man-vector contact, intermittent preventive therapy, seasonal malaria chemoprophylaxis as well as TTT for febrile patients. However, much still has to be done to target the mass testing, treatment and tracking of whole populations in order to reduce the parasite load before implementing the above mentioned interventions. Though SMC is adopted for selected localities in Ghana, MTTT could be used to drastically bring down the parasite load in a given population before the implementation of interventions such as SMC. Elsewhere, it has been demonstrated that incorporating the antimalarials in vaccination programmes could delay the first malaria episode in children under five. Furthermore, IPT of children in a community in Ghana has been reported to reduce the parasite load in a given community from 25% to 1%. The questions that remain are - could this be scaled up? What proportion of the community could be covered over a given time? What is needed to accomplish MTTT in large scale? In an ongoing pilot study in Ghana, a coverage of more than 75% was achieved in the target communities and a reduction of 24% in asymptomatic parasitaemia prevalence from July 2017 to July 2018. This proposal is intended to validate the findings of the pilot study.

In designing interventions that aim at reducing the burden of malaria in children under five, e.g, MTTT could be used to clear parasites from the general population before the interventions are implemented. This is because the adults who are not often included in the interventions that target children under 5 years old tend to act as reservoirs that fuel the transmission. To solve the problem of personnel who are limited at the level of the health service and coverage, this study will be making use of the existing network of community health workers (CHWs) that are used during vaccination programmes. The CHWs who reside in the communities, will carry out interventions in their communities and conduct the home-based management of malaria to reduce cost. To solve the problem of stock-outs of RDTs and ACTs, mobile phones SMS will be used. Monthly monitoring and of the volunteers. The volunteers will be trained based on the 2014 Ghana National Malaria Treatment Guidelines for managing uncomplicated malaria.

The study hypotheses that in the Pakro sub district, there are more asymptomatic malaria cases than the symptomatic cases reported by hospital records and that if MTTT is carried out in combination with home-based management of malaria in specific communities over two years, a large proportion of the parasite reservoir will be cleared and consequently open up possibilities for pre-elimination of malaria in the area. It is also intended that the bottlenecks involved in scaling up mass testing, treatment and tracking will be documented in order to facilitate the process.

Over the last decade, the number of recorded malaria cases has steadily dropped from 247 million cases with 881,000 deaths reported in 2006 to 216 million with 445,000 deaths in 2016 (WHO, 2009, 2010, 2016). This has largely been due to the introduction of ACTs following the resistance witnessed against chloroquine as well as an increase in the number of control measures such as the use of long lasting insecticidal nets (LLIN) and intermittent preventive treatment in pregnancy and children. Despite the reported decrease, sub Saharan Africa still bears the greatest burden of the disease where 90% of the deaths are reported with more than 75% of the mortalities in children under five.

Following the recommendation of the WHO, Ghana changed its malaria treatment guidelines adopting artesunate and amodiaquine as first line for the treatment of uncomplicated malaria to replace chloroquine. By 2012, hospital statistics across the country revealed that malaria was responsible for 38.93% of the outpatient consultations and 38.80% of admissions. Studies in Ghana have demonstrated that artesunate and amodiaquine combinations are not only efficacious in clearing the malaria parasites from patients but if used for intermittent preventive treatment for children under five could effectively clear more than 90% of the parasite in this age group.