Pakro is one of five sub-districts in the Akwapim south district health directorate (DHD) in the Eastern region of Ghana . The Akwapim south district lies within the semi-equatorial climatic region, and experiences two rainfall seasons in a year with an average rainfall of 125cm to 200cm. The first rainy season begins from May to June with the heaviest rainfall in June, whilst the second rainy season begins from September to October. According to the Ghana Statistical Service (GSS), the average household size in the Akwapim South district is 4.0 whilst the average number of households per house or compound is estimated to be 1.6 . The Pakro sub-district has an estimated population of 7,889 and is bounded to the east by Akwapim North district; to the north by Ayensuano district; and to the west by Nsawam Adoagyiri Municipality. The sub-district is made up of 22 communities, and has 3 health care facilities (1 Health Centre and 2 Community-based Health Planning Service (CHPS) compounds) . Due to limited resources, seven communities were selected for this study; Abease Newsite, Fante Town, Zongo (Adjenase/Kweitey), Piem/odumsisi, Adesa, Sacchi/Tabankro and Odumtokro. These communities had relatively higher population densities. The Pakro Health Centre is one of the thirty sentinel sites for monitoring malaria prevalence in the country coordinated by the Noguchi Memorial Institute for Medical Research (NMIMR). Malaria parasite positivity rate at the Pakro Health Centre was 45.7% in 2014 while anaemia among pregnant women at 36 weeks of gestation was 21% . To undertake this study, fourteen Community-Based Health Volunteers (CBHVs) were specifically recruited and trained for MTTT on the use of RDT test kits, treatment following the malaria treatment guidelines, and follow-up as well as reporting adverse events. CBHVs are community members without a health background.
Selection of Communities
In consultation with the district health service, we considered a 5km radius from the health facility and all 7 communities located within that zone were selected.
The entire population of about 5,000 from the seven selected communities in Pakro sub-district was enrolled in the study. This population size was obtained through the household census. Community engagement activities to sensitize the chiefs and the general population was conducted at the beginning of the study through meetings and durbars [33, 43]. All households were numbered, and community registers developed to ensure tracking of the participants. Each household was given a unique identification code. Each individual within the household was assigned a code that links them to a particular household and community. After obtaining parental informed consent, the children were enrolled but individual assent and consent was obtained from the adolescents and adults. (Fig. 1)
All community members were included in the study population. Willingness to participate was evident upon completion and signing of a consent form by the individual, parent or guardian in the case of children.
If an individual had a life-threatening illness (excluding malaria) he/she was excluded. However, all individuals including those with clinical malaria signs who were present during surveys were tested and when confirmed to carry malaria parasites were treated.
Mass testing, treatment and tracking (MTTT) of the population
The entire population of the selected communities was screened for the presence of malaria parasites using the Ag P.f RDT (SD Bioline, Standard Diagnostics, Republic of Korea) which detects histidinie-rich proteins II antigens (HRP-2 Ag) specific to P. falciparum in human blood. The RDTs were obtained from the National Malaria Control Programme (NMCP). All participants confirmed to be carrying malaria parasites were treated using an ACT following the National Malaria Treatment Guidelines . To ensure that participants adhered to treatment and to document adverse events, we followed-up participants at home after treatment on days 1, 2, 3 and 7. Each participant was observed for five minutes after treatment administration to ensure that they retain the drug. For children who vomited within five minutes of taking ACT, the treatment was re-administered as it was assumed that the drug had not been adequately absorbed. The ACTs used in this study were also obtained from the National Malaria Programme (NMCP). The drug regimen was changed at any given time depending on what the NMCP was supplying across the country. For instance, in July 2017, March 2018 and July 2018, we used artesunate-amodiaquine (AA) while in November 2017 we used artemether lumefanthrine (AL).
Fig 1: Implementation scheme of MTTT interventions in Pakro. MTTT intervention were conducted every 4 months. Between interventions, the CBHVs conducted community-based management of malaria. The time indicates the intervention periods. This report compares the parasitaemia prevalence at baseline to evaluation.
Timely treatment of suspected febrile malaria cases in the community
To facilitate MTTT, two volunteers from each community were recruited, trained and were provided with the protocol, RDTs and ACTs. Between one MTTT intervention and the next, all children and adults reporting signs and symptoms of malaria were tested by community-based health volunteers (CBHVs) using RDTs. When confirmed to be carrying the malaria parasite, the CBHVs treated the participant promptly using ACTs following the malaria management protocols provided. The research team conducted monthly monitoring visits to interact with CBHVs involved in community-based management to ensure that the protocol was being respected as well as replenish their stocks.
To facilitate tracking and improve coverage, a community register was developed. All households were numbered, and each individual assigned a unique number which is linked to a particular household. Communities were divided into neighbourhoods and volunteers were assigned a specific catchment area where they are well known. This allowed the CBHVs to schedule appointments with a particular household head before visiting to collect data. This enabled the CBHVs to come around when most of the household members were at home. In some instances, the CBHVs had to visit the houses more than one time to be able to attend to all the participants.
Following consent, blood was drawn from a finger prick. At baseline, all community participants were tested using RDTs (prevalence survey) before treatment with ACT (intervention), when positive. The data resulting from this work were stored at the Noguchi Memorial Institute for Medical Research. Hospital data was also collected during the intervention months.
Data Management and Analysis
Data was analysed using SPSS (IBM SPSS Statistics 20, United States). The unit of enrolment was the household. Malaria prevalence was reported as proportion of participants confirmed during screening to be carrying the malaria parasite, and they were stratified by demographic variables such as age, sex and community. To determine whether treating asymptomatic parasitaemia had an effect on symptomatic malaria during OPD attendance, hospital data were compared to intervention data. A Chi square statistic was used to compare prevalence of parasitaemia across age groups, gender and communities at the 95% confidence level (p = 0.05). The p-values represent changes between temporal time points. Also, a regression analysis was conducted to test the effect of factors such as timeline, age, temperature and use of LLIN on the MTTT intervention.
The protocol for this study was reviewed and approved by the Ghana Health Service Ethics Review Committee (GHS-ERC -01/03/17) and the Institutional Review Board (IRB) of the Noguchi Memorial Institute for Medical Research, University of Ghana (054/16-17). All participants signed an informed consent form prior to participating in the study. Community consent was given by the chiefs and elders while households consent was given by the household head or parents/caretakers for children below 18 years. Individual assent was obtained for children 12-17 years old while participants from 18 years old and above provided individual consent.