Dr Hamza Eltigani Omer
Khartoum Teaching Hospital, Khartoum, Sudan E-mail: heltigani2002@yahoo.com

An experimental study was conducted in the East-Nile Province aiming at involving the primary school teachers in detection of malaria among school children. 10 schools were randomly allocated into experimental or control schools. 3 focus group discussions with the school teachers were held at one school and based on it a training manual was developed. Teachers in the experimental schools were trained to use the manual for detection of malaria. A clinical algorithm of (headache, muscle/joint pains, feeling feverish) and oral temperature of 37.5 °C or higher was used for the diagnosis of malaria by the teachers. A questionnaire was developed for data collection by the teachers and laboratory technicians. For the control group, data were collected for the incidence of malaria and school absenteeism from the nearby health centres and schools, respectively.

Results Of 1242 school children referred by the school teachers in the experimental schools to the nearby health centres during the transmission season, 560 (45.1%) were identified by the teachers as having malaria. Of them, 369 (65.9%) had positive blood films. Blood films done for all referred cases revealed that 424 (34.1%) were positive for the malaria parasite. The sensitivity and specificity of the teachers in detection of malaria were 87.03% and 76.65% respectively. The positive and negative predictive values were 65.89% and 91.94%, respectively. Conclusion With little training school teachers can make a presumptive diagnosis of malaria if supported by health and educational authorities.

• Involvement of school teachers in early detection of malaria cases was beneficial in timely treatment of malaria cases, which reduced malaria morbidity among school children. In fact, none of the children in the experimental schools progressed into severe malaria compared to 1.8% of malaria cases diagnosed in the control schools. Implementing this study at a wider scale is therefore recommended in order to reduce malaria morbidity and mortality in the country.
• Training the school teachers on early detection of malaria cases let them able to detect 66% of confirmed malaria cases. Therefore, health authorities should provide regular training and supervision for school teachers in order to involve them in early detection of malaria and other communicable diseases.
• Involving school teachers in ensuring compliance to medication will reduce the emergence of resistance for the anti-malarial drugs currently used (artemesinin based combination therapy) and will reduce the period patients are infective to the mosquitoes hence would achieve malaria control.

Accurate diagnosis of malaria is essential to ensure that affected individuals receive appropriate treatment and that anti-malarial drugs are not wasted on treatment of patients with other conditions. This was overcome by using of clinical algorithms.

This approach was used in Gambia and Tanzania for diagnosis of malaria in children using clinical skills alone. These studies reported sensitivities of 86% and 99% and the specificities of 61% and 52 % respectively [1, 2].

Teachers are often influential key members in the community and thus could promote community participation in the school health programmes. They can deliver information to school children easily and are able to detect health problems early if they are taught the symptoms and signs of the disease.

This study aimed at involving the primary school teachers of East-Nile Province in the detection of malaria among the school children based on clinical algorithms.

The study was an experimental study conducted in primary schools of East-Nile Province. Of 55 primary schools, 10 were randomly allocated to either experimental or control schools, 5 schools in each group. The control schools were at a far distance from the experimental area to allow proper assessment of the impact of the intervention.

Three health centres were selected according to their accessibility to the school children in the experimental schools. Two laboratory technicians were available in each health centre during the day. Supplies and equipments were availed to the participating health centres and their laboratories which delivered free of charge services.

3 focus group discussions (FGD) were conducted, each consisted of 8 teachers, from different schools. The topics discussed were: the expected prevalence of malaria among school children, the cause of high prevalence of malaria; how malaria is transmitted; how to detect a case; role of the school teachers in detection and prevention of malaria; and how school children are referred to the health unit.

A manual for training the teachers about detection of malaria among school children was then developed guided by the FGD results. This included information about malaria in general, life cycle, symptoms and signs associated with malaria, diagnosis, treatment and prevention of malaria.

Based on that manual, 21 school teachers were trained on the detection of malaria clinically. Teachers were trained to look for the symptoms associated with malaria (headache, muscle/joint pain and feeling feverish), to measure the oral temperature using digital thermometer, to palpate the abdomen for enlarged spleen and to fill special referral form (questionnaire) for the sick child by checking the symptoms and signs. The presence of one of the following: headache, muscle / joint pain and feeling feverish with oral temperature of 37.5o C or more was the case definition of malaria.

Finally the teacher would make a presumptive clinical diagnosis as whether each was a malaria case or not, and refer the child to the nearby heath centre where the rest of the questionnaire would be filled by laboratory technician and medical assistant. Blood films for malaria were prepared for all referred children.

To ensure compliance to treatment, the teacher followed up the sick children, and reported if they improved or not. The child would be sent back to the health centre if not improved 48 hours after receiving the treatment.

For the control group, data were collected for the incidence of complicated malaria and school absenteeism from the nearby health centre and school, respectively. Standard doses of chloroquine were administered for treatment.

Of the 1242 school children referred by the school teachers to the nearby health centres for any health problem, 71% were aged between 10-14 years, and 61% were males. Microscopic examination of blood revealed an incidence of malaria episodes of 34% among these referred school children. The commonest symptoms were fever (71.3 %), headache (78.5%), muscle pain (53.1 %), joint pain (53.2 %) and other complaints (e.g. cough, eye infection, ear pain, etc.). Seventy percent of school children were referred within the first two days of their illnesses. Among the 885 (71.3%) who complained of fever, 595 (47.9%) recorded a temperature of 37.5 oC or more as recorded by the teachers. And 348 (39.3%) had fever alone and positive blood films. Suspected malaria cases by the teachers were 560 (45%), of them 369 (65.9%) were laboratory confirmed. No severe malaria cases or deaths were reported. The sensitivity and specificity of the teachers in detection of malaria were 87.03% and 76.65% respectively. The positive and negative predictive values were 65.89% and 91.94%, respectively. The sensitivity and specificity of feeling feverish in relation to oral temperature of the primary school children as recorded by the teachers were 80.17% and 36.94 %, respectively. The positive and negative predictive values were 53.9% and 66.95 %, respectively. In the control area, 1753 school children were referred by teachers to the health centres as routinely practiced. Of them, 454 (25.9%) had positive blood films for malaria, 8 (1.8% of confirmed cases) had severe malaria. Loss of days from the school due to malaria was 2- 4 days per child per malaria episode. There were no reported deaths due to malaria.

Malaria is the leading health problem in schools, hence the importance of involving school children in early detection and management of malaria. Therefore, teachers can play a major role in school health programmes and they are willing to be involved as long as that they are supported by health and educational authorities and provided with regular training and supervision.

Omer HE. ROLE OF THE SCHOOL TEACHERS IN DETECTION OF MALARIA AMONG SCHOOL CHILDREN, IN EAST NILE PROVINCE. Pediatric Oncall [serial online] 2006 [cited 2006 February 1];3. Available from:
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detection_malaria_school_children.asp