Malaria Control 54412 in Schools A toolkit on effective education sector responses to malaria in Africa Cover Photo: ©Giacomo Pirozzi / Panos Pictures Malaria Control in Schools A toolkit on effective education sector responses to malaria in Africa Partnership for Child Development London School of Hygiene and Tropical Medicine Kenya Medical Research Institute-Wellcome Trust Research Programme The World Bank December 2009 Contents List of boxes and figures II Acknowledgements III Summary IV Abbreviations and acronyms V A toolkit on malaria control in schools 1 Why this toolkit? 1 Who is this toolkit for? 1 What are the contents of the toolkit? 2 Rationale for malaria control in schools 5 Who is at risk of malaria? 5 Why is malaria control in schools important? 6 Control strategies to prevent and treat malaria 9 Insecticide-treated nets 9 Promoting use of LLINs among schoolchildren 10 Supporting community-wide LLIN distribution 10 The role of schools in monitoring malaria control programmes 11 Indoor Residual Spraying 11 The role of schools in supporting indoor residual spraying 11 Chemoprevention 11 School-based chemoprophylaxis 12 School-based intermittent preventive treatment 12 Case management and treatment 12 Presumptive treatment by teachers 13 Malaria and pregnant schoolgirls 14 Other malaria control methods 14 Skills-based malaria health education 17 How to get started? 21 Step 1: Conduct a situation analysis 21 Step 2: Ensure stakeholder participation 23 Step 3: Develop malaria control strategies which can be integrated into existing programmes 24 Step 4: Develop a national plan of action 24 Step 5: Mobilize resources 25 Additional resources 27 Useful websites 29 Glossary 31 References 33 Appendices 37 APPENDIX 1: Appendix 1: Tabulated summaries of studies investigating the impact of school-based malaria control 38 Appendix 2: Report of a national stakeholder's workshop on malaria in schools, Kenya, 2007 43 List of boxes and figures Boxes Figures Box 1 Frequently asked questions about malaria Figure 1 The relationship between age and Plasmodium and its control. 2 falciparum parasite rate in varying malaria transmission settings. 6 Box 2 Defining malaria risk among human populations. 5 Figure 2 The prevalence of Plasmodium infection among individuals of all ages in eastern Uganda, 2008, Box 3 Promoting ITN use in Kenyan schools. 10 and the proportion of the same population sleeping under an insecticide treated net. 10 Box 4 Intermittent preventive treatment in schools ­ trial results from Kenya. 12 Box 5 Pupil Treatment Kits in Malawian schools. 13 Box 6 Components of a skills-based health education approach to malaria control in schools. 17 Box 7 Key strategies to be incorporated into a skills- based malaria health education programme. 19 Box 8 Country summary of malaria distribution ­ Angola. 22 Box 9 National consensus and strategic planning for a school malaria response in Kenya. 23 Box 10 Education for All-Fast Track Initiative (EFA ­ FTI) education sector plan preparation. 25 ii List of boxes and figures Acknowledgements This toolkit was written by Simon Brooker (London School of Hygiene and Tropical Medicine, LSHTM and Kenya Medical Research Institute-Wellcome Trust Research Programme, KEMRI-WTRP), with support from members of the World Bank's Education team, led by Donald Bundy and Jee-Peng Tan, and the Booster Programme for Malaria Control, led by Anne Maryse Pierre Louis. The toolkit was reviewed by John Paul Clarke (World Bank), Brian Greenwood (LSHTM), Robert Prouty (Fast Track Initiative), and Bob Snow (KEMRI- WTRP). Additional contributions and comments were provided by Siān Clarke (LSHTM), Jan Kolaczinski (Malaria Consortium Africa), Michael Beasley (Partnership for Child Development, PCD); Keiko Inoue and Koli Banik (World Bank); Natalie Roschnik and Seung Lee (Save the Children-USA); and Cinthia Acka-Douabele (UNICEF). Editing and design work was undertaken by Anastasia Said, Francis Peel and Helen Waller (PCD). This work was funded by the Norwegian Education Trust Fund and the multi-donor Education Programme Development Fund (EPDF), both administered by the Africa Region Human Development Department of the World Bank. The results reported here contributed to the World Bank Africa Programme for Education Impact Evaluation and the Malaria Impact Evaluation Programme (see website: http://go.worldbank.org/E70Y4QHZW0). Additional support was provided by the Wellcome Trust through a Career Development Fellowship (081673) to Simon Brooker. Acknowledgements iii Summary The Malaria Control in Schools toolkit has been designed to help policymakers, health professionals, educationalists, researchers, donors and non- governmental organizations on how to implement country-led plans for school malaria programmes. The WHO Globlal Malaria Programme recognizes the importance of the education sector and the role that schools and teachers can play on the prevention and control of malaria. The FRESH framework for school health, adopted by majority of African countries, has the ability to deliver school-based malaria interventions. This toolkit uses this infrastructure on how effective malaria control interventions can be implemented in schools. Practical up-to-date information and experience on the control of malaria in schools is presented with both technical and policy advice on malaria, and how countries can plan and implement school-based malaria interventions. Useful links and technical resources specific to information on malaria as well as health education and school health are also provided. This toolkit will help users to understand why the education sector should respond to malaria; the benefits of controlling malaria in schools; the appropriate malaria interventions which can be delivered through schools; examples of promising practice at scale; the key issues in developing a school malaria programme; how to formulate a national Malaria Control in Schools strategy; and how to design a malaria component of a wider school health programme. The global situation on malaria is in transition, with evidence of declining transmission and disease burden. As transmission declines, school-age children will increasingly become an important clinical risk group. Within this context, it is hoped that the Malaria Control in Schools toolkit will facilitate professionals within the education sector to develop effective programmes on the prevention and control of malaria for school-age children within malaria endemic countries. iv Summary Abbreviations and acronyms ACTs Artemisinin-based Combination KESSP Kenya Education Sector Support Therapies Programme AIDS Acquired Immune Deficiency Syndrome KIE Kenya Institute of Education AMREF African Medical and Research LePSA Learner-centred, Problem-posing, Self- Foundation discovery, Action-oriented approach AQ Amodiaquine LLIN Long-lasting insecticidal net AS Artesunate LSHTM London School of Hygiene and Tropical Medicine DDT Dichlorodiphenyltrichloroethane MDG Millennium Development Goal ECD Early Child Development MoE Ministry of Education EFA-FTI Education for All ­ Fast Track Initiative MoH Ministry of Health EPDF Education Programme Development NGO Non-governmental organization Fund NMS National Malaria Strategy ESACIPAC Eastern and Southern Africa Centre of PCD Partnership for Child Development International Parasite Control PfPR Plasmodium falciparum parasite rate ESP Education sector plan PSI Population Services International FRESH Focusing Resources on Effective School Health PTA Parent Teachers Association Hb Haemoglobin RBC Red blood cell HIV Human Immunodeficiency Virus RBM Roll Back Malaria IEC Information, Education and RDT Rapid diagnostic test Communication SCN Standing Committee on Nutrition IPT Intermittent preventive treatment SHN School Health and Nutrition IPTc Intermittent preventive treatment in SP Sulfadoxine-pyrimethamine children SWAp Sector-Wide Approach IPTi Intermittent preventive treatment in infants UNESCO United Nations Educational, Scientific and Cultural Organization IPTp Intermittent preventive treatment in pregnancy UNICEF United Nations Childrens Fund IRS Indoor residual spraying UPC Universal Primary Completion ITN Insecticide-treated net WFP World Food Programme KeNAAM Kenya NGO Alliance Against Malaria WHO World Health Organization Abbreviations and acronyms v A toolkit on malaria control in schools Why this toolkit? gap, this toolkit provides an overview of existing knowledge and experience regarding the control of With the global momentum to ensure universal primary malaria in schools. Technical and policy advice is education, more children than ever before are attending provided on how the education sector can respond to school, and governments are increasingly recognizing malaria. Practical up-to-date how to information is also the importance of child health for educational provided to aid the effective implementation of school achievement1. Among the main health problems malaria programmes. The Malaria Control in Schools afflicting schoolchildren, malaria is an important cause toolkit aims to assist countries in planning and helps to: of mortality and morbidity, and may have profound consequences for learning and educational achievement1. Yet surprisingly, little is known about the · Highlight why the education sector should burden of malaria in schoolchildren or what schools respond to malaria. should do about malaria3-5. · Understand the benefits of controlling malaria in schools. School-based health and nutrition programmes are a cost-effective strategy to alleviate a number of the · Define the appropriate malaria interventions health problems facing schoolchildren, and already which can be delivered through schools. provide them with health education and health services · Learn from examples of promising practice at such as deworming and micronutrient supplementation. scale. These interventions are simple, safe and familiar, and address problems that are widespread and recognized · Identify the key issues in developing a school as important within the community. A major step malaria programme. forward in international coordination was achieved when · Formulate a national Malaria Control in Schools a global framework for school health programmes was strategy. developed to form a partnership in "Focusing Resources on Effective School Health (FRESH)". Among the early · Design a malaria component of a wider school partners were the United Nations Educational, Scientific health programme. and Cultural Organization (UNESCO), the United Nations Childrens Fund (UNICEF), the World Bank, the World Food Programme (WFP), and the World Health The contents included in this toolkit apply to Organization (WHO), with the Education Development malaria endemic countries, with a specific focus Centre, Education International, and the Partnership for on sub-Saharan Africa, where the malaria burden Child Development (PCD)6. The FRESH framework is greatest. The toolkit also draws on relevant includes the following core components: information from Asia, where examples are documented. The Malaria Control in Schools toolkit complements · School health policies that advocate the role of and expands upon the FRESH toolkit which presents teachers in health promotion and delivery. essential components of school-based programmes and · Safe water and sanitary school environments. provides policymakers with information on how best to identify and effectively address school health problems6 · Skills-based health education that promotes (see www.freshschools.org/Documents/FRESHandEFA- good health. English.pdf). · Basic school-based health and nutritionservices. The FRESH framework has been adopted by a majority Who is this toolkit for? of countries in Africa as the organizing principle for school health programmes. This existing infrastructure The Malaria Control in Schools toolkit aims to provide has the ability to deliver school-based malaria sector professionals with practical up-to-date interventions. The role that schools and teachers can information to aid the effective implementation of play in the prevention and control of malaria is also country-led plans for school malaria programmes. recognized by the WHO Global Malaria Programme7. Users include policymakers, and implementers of school health programmes. Educationalists, researchers, donors There is currently no consensus as to the optimal and non-governmental organizations (NGOs) will be able approach on how available interventions can be to use this toolkit to help determine priorities for implemented in practice. To help fill this information funding and implementation. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 1 BOX 1: What are the contents of the toolkit? Frequently asked questions about malaria and its control The toolkit presents information to help sector professionals develop strategies that can be tailored to What is malaria? specific programmatic and epidemiological settings. This information is set out as: Malaria is a common and serious tropical disease. It is an infection transmitted to human beings by mosquitoes · Rationale for malaria control in schools. biting mainly between sunset and sunrise. Human malaria is · Control strategies to prevent and treat caused by four species of Plasmodium protozoa parasite: malaria involving: Plasmodium falciparum, P. vivax, P. ovale and P. malariae. · principles and tools of malaria control for school-based programmes; How is malaria transmitted? · skills-based malaria health education Malaria is most commonly transmitted through the bite of an programmes; and infected anopheline mosquito. Malaria can also be transmitted by blood transfusion, and in rare instances, by contaminated · summaries of studies investigating the impact of school-based malaria control ­ needles and syringes. In congenital malaria, parasites are Appendix 1. transmitted from mother-to-child before and/or during birth. · Example of practices at scale ­ Boxes 3, 4 Who is at risk of malaria? and 5. Plasmodium falciparum causes severe and life-threatening · How to get started? malaria. Anyone can get malaria. However, people who are · A national stakeholders workshop on heavily exposed to the bites of mosquitoes infected with malaria in schools ­ Appendix 2. Plasmodium falciparum are most at risk of malaria. People who · Key links and resources to specific information have little or no immunity to malaria, such as young children and on malaria control. pregnant women are more likely to become very sick and die. School-age children can also be at risk of infection and disease. · Glossary of terms. What are the main symptoms of malaria? Questions that are frequently asked about malaria and its control are presented in Box 1. The classical clinical course of malaria consists of fever and flu- like illness, including shaking chills, headache, muscle aches, and tiredness. Nausea, vomiting, and diarrhoea may also occur. Malaria may cause anaemia and jaundice (yellow colouring of the skin and eyes) because of the loss of red blood cells. Infection with Plasmodium falciparum, if not promptly treated, may cause kidney failure, seizures, mental confusion, coma, and death. How is malaria diagnosed? The clinical diagnosis of malaria is difficult under the best of circumstances. Definite diagnosis is based on light microscopic observation of parasites in the red blood cells of the patient. Newer diagnostic tools include antigen detection in the form of a dipstick, known as rapid diagnostic tests (RDTs). 2 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa BOX 1: Frequently asked questions about malaria and its control How can malaria be controlled? The goal of malaria control is to prevent mortality and extensive use; and secondly, there were also concerns over DDT reduce morbidity and social and economic losses, through the poisoning both wildlife and the environment. There is now a progressive improvement and strengthening of local and national worldwide ban on the agricultural use of DDT. However, there is capabilities. Four basic technical elements of the malaria control little evidence that using DDT endangers human health when DDT strategy are: is used appropriately for IRS. DDT has long been the cheapest insecticide and the one with the longest residual efficacy against - Insecticide-treated nets (ITNs) or long-lasting insecticidal malaria vectors (6 to 12 months). nets (LLINs) to protect populations at risk of malaria. - Indoor residual spraying (IRS). What are the current insecticides being used? - Prompt access to treatment with effective antimalarials, such as Artemisinin-based Combination Therapies (ACTs). Pyrethroids (i.e., Deltamethrin and Cyfluthrin) are the most - Prevention of malaria in pregnant women, through commonly used. Organophosphates (i.e., Malathion) and measures such as Intermittent preventive treatment (IPT) carbamates are also used but these all generally have shorter and the use of LLINs. residual effect (up to 6 months). What is a long-lasting insecticidal net (LLIN)? Should schools be sprayed with insecticides? It is a bed net which is manufactured with long-lasting insecticide Yes, all schools and other public buildings should be sprayed with directly incorporated into its fibres, hung over a bed to protect insecticides. Dormitories of boarding schools should also be sleepers from insect bites. The insecticide adds a chemical barrier sprayed. to the physical barrier provided by the net. LLINs have the advantage over previous insecticide-treated nets (ITNs) in that the What are Artemisinin-based Combination insecticidal activity is not lost during washing. Therapies (ACTs)? Which insecticides are commonly used These are treatments for uncomplicated falciparum malaria that to treat nets? combine several antimalarial drugs, one of which is a derivative of artemisinin. The most common artemisinin derivatives used in A group of insecticides called pyrethroids, especially permethrin, ACT are artesunate (AS), artemether and dihydroartemisinin. deltamethrin, and lamda cyhalothrin. These are usually used in combination with other antimalarials to treat the parasite. These combina-tions are called artemisinin- What is indoor residual spraying (IRS)? based combination therapies, or ACTs, and are now the recommended first line of treatment for malaria in most countries IRS is the application of long acting (6 to 12 months) insecticides in Africa. to the walls and eaves of houses and, in some cases, public buildings and domestic animal shelters, in order to kill adult Why use ACT? mosquitoes that land and rest on these surfaces. It aims to reduce transmission by decreasing mosquito survival and density. Resistance to older drugs including chloroquine and sulfadoxine- Spraying is done at stated intervals typically using a hand- pyrimethamine (Fansidar) is now widespread, making them operated compression sprayer. Previously, the cheapest and ineffective to treat clinical malaria. ACTs combine drugs with probably the most effective insecticide for malaria control was different modes of action which considerably reduces the risk of dichlorodiphenyltrichloroethane (DDT). resistance developing. ACTs also produce the fastest clinical recovery because the artemisinin kills parasites more rapidly than Is DDT still used for IRS? any other malaria drug. ACTs are active against parasite stages called gametocytes (the sexual stage of the parasite cycle), which No, DDT is not used for IRS for two main reasons: firstly, help reduce the risk of transmission from one treated patient to resistance in mosquitoes had begun to develop as a result of another person. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 3 BOX 1: Frequently asked questions about malaria and its control What are the disadvantages of ACTs? Can IPT be given to other age groups? ACTs are expensive, costing up to US$ 3 per treatment. The A number of research studies have investigated the impact of IPT dosage regime is also complicated, resulting in lower levels of given during infancy (IPTi) as a malaria prevention approach in adherence to full course of treatment. sub-Saharan Africa. The treatment is given on the regular infant immunisation schedule. An independent international committee Can ACTs be used in pregnancy? found that IPTi using sulfadoxine-pyrimethamine (IPTi-SP) is safe and efficacious. IPT has also been successfully given to children The safety of ACTs in pregnancy is not fully known. up to the age of 5 years and to school-age children. It is currently recommended that in the first trimester, the ACTs drug should be avoided as first line treatment for uncomplicated Can IPT be given in schools? malaria. However, WHO has recently recommended that they can be used in all trimesters if the life of the mother is at risk, and in To date, two studies have evaluated the impact of IPT among the second and third trimesters, to treat uncomplicated malaria, schoolchildren. A study in Kenya showed that IPT given once a if there is no other suitable drug. term markedly reduces rates of anaemia and malaria infection and improved cognition. Another study in Mali found that IPT What about artemisinin resistance? reduced rates of anaemia and clinical attacks. At present, there is no evidence of parasite resistance to What about resistance due to IPT? artemisinins. This is not to say that resistance to the artemisinins will never happen; the best way to protect the artemisinins from Because treatment is provided only periodically, individuals still resistance is to combine them with another effective drug. become infected with malaria parasites which are not exposed to the drug. This helps to reduce the emergence of drug resistance, Why not use ACTs in school-based but sufficiently reduces the number of parasites harboured by an programmes? individual. There is a consensus that the drugs used for IPT should differ Is there a vaccine for malaria? from drugs used for first-line treatment of clinical malaria (which is typically ACTs). No. There is currently no malaria vaccine approved for human use. The malaria parasite is a complex organism with a What is intermittent preventive treatment complicated life cycle. The parasite is constantly changing and (IPT)? developing a vaccine is therefore very difficult. However, many scientists all over the world are working on developing an IPT is the periodic mass administration of a full therapeutic course effective vaccine. of an antimalarial drug, irres-pective of infection status. Intermittent preventive treatment of malaria in pregnancy (IPTp), which is administered at the time of antenatal clinic visits, is recommended by WHO for preventing malaria during pregnancy. For IPTp, WHO currently recommends the use of sulfadoxine- pyrimethamine. 4 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Rationale for malaria control in schools Who is at risk of malaria? BOX 2: Globally, malaria poses an enormous public health burden, with the majority of clinical episodes due to Defining malaria risk among Plasmodium falciparum occurring in sub-Saharan Africa8. human populations In areas of moderate or high malaria transmission (see Box 2), mortality is greatest among young children. The major causes of childhood death are cerebral malaria, severe malaria anaemia and respiratory distress caused The amount of malaria may vary considerably between different by acidosis (see Glossary). Young children who survive geographic areas. Malaria is often classified according to cerebral malaria may be left with debilitating whether transmission is stable or unstable. These situations neurological impairments. form a continuum of differing settings. The continuum is also sometimes referred to as ranging from high through moderate Older children and adults, who have been regularly to low. exposed to malaria, typically acquire immunity to clinical malaria and most malaria infections generally remain Stable transmission: This situation occurs when the prevalence clinically asymptomatic. However, during pregnancy, of malaria infection is persistently high and transmission is year women are more susceptible to clinical disease, with round (perennial) and relatively insensitive to seasonal and infection of the placenta associated with maternal environmental/climatic changes. High levels of immunity develop anaemia and low birth weight9. within the population due to regular exposure to malaria Since school-age children have generally acquired parasites. Transmission is said to be high or moderate in immunity to malaria, they tend to suffer less mortality such settings. and morbidity from malaria than their younger siblings10 although pregnant schoolgirls may be an exception to Unstable transmission: This situation is when malaria this generality. However, though mortality and morbidity transmission is low and varies greatly in space and time, often may be low in areas of high malaria transmission, it is in relation to environmental/ climatic factors. Immunity is low not insignificant, and is of substantial importance of the and there is a propensity for epidemics to occur. education of schoolchildren through reduced school attendance, cognition, learning and school performance2,4,11. In areas of unstable or epidemic-prone transmission (see Box 2), where children and adults have little or no pre-existing immunity to malaria, infection is associated with a high risk of life threatening disease that needs to be treated promptly and effectively. However, these risks are balanced by the low, and often very seasonal, exposure to the parasite. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 5 Why is malaria control in · To maximize the impact of current control schools important? efforts, everyone, including school-age children, should be protected. Targeting limited subsidies to maximize personal protection of the This section explains why malaria in schoolchildren is most vulnerable ­ young children and pregnant important and highlights the role the education sector women ­ should remain a priority, but more can play in malaria control in schools and in the wider equitable and effective suppression of risk for entire community. The arguments presented can be used in populations can be attained with quite modest particular, to convince policymakers and decision coverage (20% to 50%) across all ages. This is makers, as well as others of the importance of malaria because over 80% of human-to-mosquito prevention and control in schools. transmission originates from older children and adults since these groups constitute the bulk of Argument: Malaria control the population and are more attractive to mosquitoes14. among all age groups, including school-age children, is required · Older children going to school may be at to achieve large reductions of increased risk in the future. As the movement to increase insecticide-treated net (ITN) or long-lasting the malaria burden in Africa. insecticidal net (LLIN) coverage among young children continues its current momentum in Africa, clinical immunity to malaria will be acquired slower · School-age children represent 26% of Africa's and the distributions of morbidity and mortality will population and an increased proportion of shift into older age groups, requiring protection of these children are going to school. In sub- all members of the population, including school-age Saharan Africa since 2000 there has been a 52% children. increase in pupil enrolment12, increasing the Argument: Malaria is one of number of children who could benefit from a systematic approach to school-based malaria control. the major health problems · The proportion of individuals who are infected confronting schoolchildren. with malaria parasites is highest among school-age children. Studies in varying · Malaria accounts for up to 50% of all deaths transmission settings reveal that the prevalence of among African school-age children. This infection has a consistent relationship with age, with represents an estimated 214,000 deaths per prevalence rapidly rising in among young children, year15. attaining a maximum in the age range between 5 to 15 year olds, and declines among adolescents and · Malaria frequently occurs among young adults (see Figure 1). schoolchildren. Studies indicate that 20% to 50% of African schoolchildren living in areas of stable high transmission experience clinical malaria attacks each year16. However, the burden of malaria among schoolchildren will vary according to the intensity of malaria transmission17. While the risk of clinical attack is lower in areas of unstable malaria transmission, the attacks are more severe as children have not acquired any significant level of immunity. · Malaria causes anaemia among school-age children. Although there are a complexity of factors that cause anaemia, including nutritional deficiencies and helminth infections, evidence suggests that malaria is a major cause of the condition18. Efforts to control malaria among school-age Figure 1: The relationship between age and Plasmodium falciparum children can dramatically improve haemoglobin (Hb) parasite rate in varying malaria transmission settings. Note: Shaded levels19. box indicates typical age range of primary schoolchildren (between 5 years to 14 years) in sub-Saharan Africa. Source: Brooker et al., 200913. 6 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa · Pregnant schoolgirls are at high risk of Argument: Schools provide an entry point for malaria malaria. In Africa, up to a quarter of girls give birth before the age of 18 years; as such, malaria in pregnancy is important when considering malaria in prevention and control. schoolchildren2. Pregnancy-associated malaria is a major cause of low birth weight and maternal Schools have the mandate and responsibility to enhance anaemia in areas of stable transmission20,21, all aspects of the development of children, including with severe anaemia during pregnancy being a their health30. They also provide an effective way to major risk factor for maternal death. In reach a large portion of the population, including future Mozambique, for example, 27% of deaths in pregnant women and parents of young children ­ the adolescent pregnant girls were caused by most biologically vulnerable populations. malaria22. · Malaria is perceived as a problem by Argument: Malaria is a leading schoolchildren, parents and teachers. This cause of illness and absenteeism perception enhances community involvement and responsibility for malaria control in schools. among students and teachers and impairs attendance and · Teachers can teach skills on how to prevent malaria. Teachers have professional training in learning. disseminating information and are in contact with children at a critical age of their development during which life skills, including those related to malaria · Malaria causes between 4 to 10 million days of prevention and control, can be developed. For school absenteeism per year in Africa. Studies in example, teachers can provide children with the Africa indicate that malaria contributes between 5% knowledge and skills they need to use ITNs to 8% of all-cause absenteeism, equivalent to 50% throughout their life, including when they become of all preventable absenteeism, and around 4 to 10 future parents to the next generation of at-risk million school days lost per year4. Absenteeism is children. a particular concern during a malaria epidemic in areas of unstable transmission23. Fortunately, · Schools can support community-wide malaria preventing malaria in early life is associated with control. Schools are a central part of the longer schooling24. community and can enhance community-wide malaria control30,31. While families of schoolchildren · Malaria impairs cognition, learning and may lack knowledge on ways to prevent and treat educational achievement. These effects appear to malaria they can learn about how to control malaria be mediated through two pathways: the anaemia from their own children. Schools have legitimacy in that is associated with both asymptomatic and the community and are thus, an effective gateway clinical malaria; and the neurological consequences for schoolchildren to disseminate messages of cerebral malaria11,25. Recent evidence to their parents and to the wider community where suggests that non-severe malaria can adversely schoolchildren can be important agents of change. affect cognition, attention and, ultimately, school Similarly, effective community partnerships can performance26,29. enhance and reinforce the malaria control activities in schools. · Malaria can also impact on education supply. This occurs through the malaria-related death and Argument: There is a clear policy context for the educational absenteeism of teachers. In areas of unstable transmission absenteeism of teachers can lead to the closure of schools during the malaria response to malaria. transmission season23. Previous experience has shown that stand-alone school · Reducing the educational burden of malaria is malaria programmes are not always effective or integral to the Millennium Development Goals sustainable. Rather, it is important to see malaria in (MDGs). Addressing malaria is crucial to meeting schools as part of a broader school health programme. many of the MDG targets, in particular goal 2, in The multi-agency FRESH initiative provides a framework `achieving universal primary education'. for determining how an integrated school health package can be developed and which can include malaria. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 7 Sponsored by UNESCO, UNICEF, WHO, the World Bank of mosquito breeding sites, with advice issued to and other partners, the FRESH framework calls for four schoolchildren to destroy potential mosquito areas of concerted action in all schools: school health breeding areas; however, the impact of these efforts policies; water, sanitation and the environment; skills- remains uncertain. Boarding schools can set a based health education; and school-based health positive example by providing screening on services. Malaria can be dealt within these four dormitory doors and windows. components of the FRESH framework: 3. Skills-based health education: This is the most 1. School health policies: Education sectors perceive common component of school health programmes. malaria as a major challenge, and recognize the With respect to malaria, the focus tends to be on the impact of malaria on both schoolchildren and biology of infection and less often, on the teachers. There is a lack of consensus as to the recognition of symptoms. Advice on treatment is response, however, and there is a need for clear usually confined to seeking attention in clinics. policy guidance. Policies are needed that make clear the role of teachers in health promotion and the 4. School-based health services: This is the delivery of treatment. However, any policy on area of most controversy and the area in which malaria in schools needs to be consistent with specific guidance on malaria control is most lacking. national malaria policies. Recognizing the information gaps in what schools can 2. Water, sanitation and the environment: do about malaria, the next section presents the general During the malaria campaigns of the 1950s and principles and tools of malaria control and evaluates 1960s there was considerable focus on the reduction their appropriateness for use within the school context. 8 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Control strategies to prevent and treat malaria The WHO Global Malaria Programme recommends four As the insecticidal activity on ITNs is mainly lost during main evidence-based cost-effective interventions that washing, LLINs are an alternative, practical and can reduce the burden of malaria mortality and sustainable method for protection against malaria; as a morbidity: result LLINs are now replacing conventional ITNs. While the initial cost of LLINs is higher (US$4 to US$6 per net) · Insecticide-treated nets (ITNs) or long-lasting than for traditional nets, LLINs become more cost- insecticidal nets (LLINs) to protect populations effective within 2 years of use because they require no at risk of malaria. additional insecticide treatment. An evaluation in Kenya · Indoor residual spraying (IRS). showed that nationwide, free mass distribution of LLINs was a powerful way to quickly and dramatically increase · Prompt access to treatment with effective coverage, particularly among the poorest people, antimalarials, such as Artemisinin-based thereby reducing the health burden of malaria34,35. Combination Therapies (ACTs). · Prevention of malaria in pregnant women, through Previously, global guidelines focused primarily on measures such as intermittent preventive treatment providing ITNs for use by children under the age of (IPT) and the use of LLINs. 5 years and pregnant women, and these populations remain the priority target group. However, it has been While malaria has been included in the school health recently recognized that protecting all community priorities for FRESH, there has been international members yields enhanced health benefits and social consensus on the need for only health education; there equity14,35, and therefore: is, at present, inconsistent policy advice on appropriate school-based malaria interventions. As part of its Cover the Bed Net Gap initiative WHO, UNICEF and other partners recommend This section presents the general principles and tools that LLINs should be distributed freely or of malaria control as recommended by WHO and also should be highly subsidized and used by all presents other control options including chemo- community members, including schoolchildren prevention and indoor residual spraying. (see www.malariaprogress.org). This section further discusses the relevance of these tools for a school-based programme based on empirical This recommendation is a direct response to the United evidence. Summaries of the evidence for school-based Nations Secretary-General Ban Ki-moons call for malaria control interventions reported in this section are universal coverage of malaria control in Africa. For this tabulated in Appendix 1. to occur there would need to be dramatic increases in coverage to schoolchildren due to the current low levels Insecticide-treated nets of LLIN use among this age group36(see Figure 2). This implies providing free LLINs to schoolchildren, encouraging the very large number of boarding schools ITNs are mosquito nets treated with an insecticide. to provide nets in dormitories, and supporting the The insecticide adds a chemical barrier to the physical strategy with skills-based malaria health education, to barrier provided by the net. ensure that schoolchildren develop the knowledge, attitudes and skills necessary to reduce their risk Research over the last two decades has shown that from malaria. the use of ITNs substantially reduces mortality, severe malaria and infection, as well as reducing rates of anaemia among young children32. There is also well documented evidence on health gains for pregnant women who use ITNs33. Thus, ITNs represent a practical and effective means to prevent malaria, and scaling up coverage to at least 80% use by young children and pregnant women is a consensus target of the MDGs, the Global Malaria Programme, and the United States Presidents Malaria Initiative. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 9 · In Kenya, schoolteachers were paired with health workers to provide messages using interactive learning methods including a 30-minute play, small group work to discuss the play and a poster competition40. Although this increased childrens awareness of ITN, the messages were not always effectively transferred to parents at home. · In Burundi, schools as well as health facilities, were used to hold meetings to promote ITNs as a tool for malaria control and to convince families to buy at least one net 41. Two years later a reduction in malaria infection among under-fives had been achieved, but no reduction was observed among children aged between 5 to 9 years. Figure 2: (1) the prevalence of Plasmodium infection among individuals of all ages in eastern Uganda, 2008 (closed circles), and (2) the proportion of the same population sleeping under an insecticide treated net (open circles). Source: Pullan et al., 2010 (in press).78 BOX 3: Promoting ITN use in Kenyan schools Promoting use of LLINs among schoolchildren The Population Services International (PSI) schools project was a pilot effort to promote ITN use among Kenyan schoolchildren Although there is specific WHO advice on promoting the and their families. Implemented in 2005, this project produced use of LLINs among school-age children30, there are few positive results by bringing together an NGO and the business empirical examples of the impact of this strategy: sector to develop a pupil booklet and a teachers guide on the effective use of ITN by schoolchildren and their families. The key · Evidence from the 1980s found that sleeping features of the programme were: under untreated mosquito nets following a round of effective antimalaria treatment reduced malaria attacks, but did not reduce anaemia, among children · Effective collaboration between an NGO and a in a rural boarding school in Kenya37. development communication company, which developed and piloted the pupil booklet and teachers guide. · A community-based trial of permethrin-treated mosquito nets in rural Western Kenya, showed · Each booklet contained a questionnaire on ITN use by that the use of ITNs halved the prevalence of the pupils family and the teachers were provided with mild all-cause anaemia in adolescent a poster to collate information on ITN coverage; schoolgirls, aged 12 to 13 years37, but was incentives were offered to each participating class in less effective in preventing anaemia among the form of badges and certificates for pupils and younger children. t-shirts for teachers. The long-term sustainability of Schoolteachers should relay simple messages to these incentives is unclear, however. schoolchildren encouraging them and their families to sleep under a LLIN, thereby increasing uptake of this · A second round of questionnaires were sent out existing effective intervention. Moreover, promotion of 3 months later where the results showed that ITN use LLINs in schools would be of particular benefit for had doubled; this increase was confirmed by separate pregnant adolescent girls, who are most vulnerable to community-based surveillance. the risk of malaria, but the least likely to use a LLIN during pregnancy39. An innovative approach to · The estimated cost of the programme was US$0.60 per promoting ITNs among schoolchildren and their families child reached. through schools comes from Kenya (see Box 3). · The learning of key lessons, which included the Supporting community-wide importance of appropriately informing district LLIN distribution Ministries of Health and Education staff to enhance inter-sectorial collaboration; further efforts were needed to ensure the sustainability and scaling up Schools can also support community-wide interventions of such an approach. such as LLIN distribution, thereby helping to maximize coverage rates. For example: Source: PSI [personal communication]. 10 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa The role of schools in monitoring to increase overall IRS coverage in the area, or if malaria control programmes schools are stand-alone structures away from any communities. Although, most often schools in or near communities are sprayed when there are no plans to Schools provide an established system to help monitor provide IRS to the community at large; however, there the coverage of community-wide implementation of appears to be no evidence that this approach provides ITNs. In Uganda, for example, the use of schools as complete protection to schoolchildren. Thus: sentinel sites for monitoring ITN coverage has been piloted. It was found that reports from schoolchildren on IRS in schools should be implemented net ownership in their households provide a cheap and as part of a wider community-based relatively fast method to collect reliable coverage data integrated vector management strategy. at community level. The additional work involved in administering questionnaires to the pupils did not Schools can also disseminate simple messages on the appear to pose any problems to the teachers 42,43. need, purpose, method and timing of community-wide IRS, to ensure that households prepare for the arrival of the spray team thereby allowing access to their homes. Following the guidance by WHO, UNICEF and other partners, it is recommended that schools promote the use of LLINs among school- Schools have an important role in supporting children and their families. Schools also have IRS programmes by providing education a potentially important role in supporting the messages on the need, purpose, method distribution and use of LLINs to all community and timing of spraying. Schools including members. residential schools should implement IRS as part of a wider community-based integrated vector management strategy. Indoor residual spraying Indoor residual spraying (IRS) is the application of long Chemoprevention acting (6 to 12 months) insecticides to the walls and There are two main approaches to the chemotherapeutic roofs of houses and, in some cases, public buildings and prevention of malaria: domestic animal shelters, in order to kill adult vector mosquitoes that land and rest on these surfaces. It aims 1. Chemoprophylaxis is the regular (daily or to reduce transmission by decreasing mosquito survival weekly) administration of drugs in sub- and density. therapeutic doses over a sustained period of time to all individuals, irrespective of infection IRS is a valuable approach in controlling malaria at the status, in order to obtain persistent protective community level, but it requires the spraying of all or levels in the blood. Regular chemoprophylaxis is most residential accommodations within target currently only recommended for non-immune communities to effectively reduce malaria transmission travellers to malaria endemic areas. and thus, risk within an area. 2. Intermittent preventive treatment (IPT) IRS has recently received increasing attention as a is the periodic mass administration of a full component of malaria control in many countries. Past therapeutic course of an antimalarial, experience has shown that the logistics of implementing irrespective of infection status. WHO currently spraying at high quality and on a regular basis are recommends giving IPT to pregnant women extremely challenging. It is therefore advisable to (IPTp) regardless of their infection status during consider IRS as one of the possible options for vector their second and third trimester. control, rather than as the definite solution. Recent research shows that IPT given during the first The role of schools in supporting year of life at the time of routine immunizations (so indoor residual spraying called IPTi) reduces malaria and anaemia44. IRS in boarding schools is an important component in Studies in West Africa, for example, have demonstrated achieving community-wide coverage, to protect school- that seasonal IPT can be an effective malaria prevention children at night. Spraying of schools is important if strategy among children under 5 years of age in areas they are in or near a community that is being sprayed, of seasonal malaria transmission45,46. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 11 School-based chemoprophylaxis Historically, school-based delivery of malaria BOX 4: chemoprophylaxis was associated with significant reductions in malaria-related morbidity and mortality, Intermittent preventive treatment in and improvements in educational outcomes19,47, but fell schools ­ trial results from Kenya out of use in Africa due to financing problems48 and with the emergence of malaria drug resistance49. More recent evidence suggests that weekly chemoprophylaxis can improve school examination scores27, but tends to A novel approach to control malaria in schoolchildren was be compromised by declining compliance and coverage recently tested in a cluster-randomized placebo-controlled trial over time. However, no chemoprophylaxis regime in 30 primary schools in Western Kenya. The impact of IPT on provides full protection and should be followed with anaemia and school performance was compared between other malaria control measures such as LLINs. intervention and control schools after 1 year. The key features of School-based intermittent the trial were: preventive treatment · IPT was administered once every term, to all children (aged between 5 to 18 years old). The drugs used An alternative strategy, already proven effective for were SP and AQ, given in combination, over protecting the health of young children and pregnant 3 consecutive days. women, is IPT. In Kenya, the mass administration of a · The use of IPT reduced the occurrence of anaemia full therapeutic course of antimalarial drugs (sulfadoxine-pyrimethamine {SP} and amodiaquine by 48% after three terms. {AQ}) to schoolchildren once a term, irrespective of · There was an 89% reduction in the occurrence of infection status, dramatically reduced malaria malaria infection. parasitaemia, almost halved the rates of anaemia and significantly improved cognitive ability26 (see Box 4). In · Significant improvements were also seen in class- an area of moderate seasonal malaria transmission in based tests of sustained attention. Mali, IPT using SP and artesunate (AS) or AQ and AS among school-age children not only reduced rates of In the study, IPT was administered by the research team; anaemia and parasitaemia but also rates of clinical however, the feasibility of involving teachers in drug attacks50. administration was also explored with parents and teachers. The intervention was found acceptable to pupils, parents and IPT is likely to be most applicable in areas of perennial teachers and generally seen as beneficial. Teachers expressed stable transmission, where malaria infections in a willingness to administer IPT in schools with training and schoolchildren are usually asymptomatic and likely to go untreated. IPT may also help prevent clinical attacks of support from local health authorities. The programmatic delivery malaria for a short period immediately after drug of IPT by teachers was estimated to cost US$1.88 per child treatment, which could be beneficial in schoolchildren per year. living in areas of more seasonal transmission, such as large parts of West Africa. Source: Clarke et al., 2008; and Temperley et al., 200826, 51. However, before there is widespread implementation of IPT in schools, a number of issues require further investigation: optimal drug regimen (including drug Case management and treatment efficacy, ease of administration, costs, availability, Case management is the administration of a complete, acceptability, safety and tolerability); cost-effectiveness; effective antimalarial treatment and provision of and the impact in different transmission settings. necessary supportive care to a person with malaria-like symptoms within 24 hours of the onset of symptoms, unless a diagnostic procedure has shown that the IPT in schools holds promise for a school-based malaria patient does not have malaria52. strategy, although it is still necessary to evaluate the effectiveness of the approach in a wider range of infrastructure and malaria transmission settings in Africa. 12 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Until recently, the first line treatment in most African countries was either chloroquine or SP. In the face of rapidly increasing SP resistance, the WHO currently BOX 5: recommends treatment with ACTs. Until such time as Pupil Treatment Kits in ACTs can be made widely available, a non-artemisinin- based combination such as AQ plus SP may be Malawian schools considered as an interim strategy in countries where the efficacy of both drugs remains high. Confirmation of a malaria diagnosis through microscopy or rapid diagnostic tests (RDTs) is rarely undertaken owing to A school health and nutrition programme in Malawi, supported by Save the lack of resources and infrastructure at peripheral the Children (USA), evaluated the programmatic use of presumptive health facilities and overdiagnosis and treatment of treatment in 101 schools in the Mangochi District. Started in 2000, the malaria is common. project trained teachers to treat malaria in schools using a Pupil Treatment Kit including SP. The key features of the programme were: Presumptive treatment by teachers · In each school, three teachers received training, including recognition of the signs and symptoms used to diagnose While prevention and health education are traditional malaria and safe administration of antimalarial treatment. and natural activities by which schools contribute to disease prevention, there appears to be unclear · Sick children were reported to teachers and suspected guidance on whether antimalarial treatment services can malaria cases were treated with SP according to the national be provided through schools. This is due in part to guidelines where antipyretics were provided to the sick limited evidence, with few studies investigating the children to take home. Sick children whose health did not effectiveness of treatment by teachers: improve were referred to a health facility. · In a pilot study in Tanzania, teachers used a · The overall and malaria-specific mortality rates for the combination of symptoms and oral temperature 3 years before and 2 years after the intervention dropped from to diagnose malaria and used chloroquine for 2.2 to 1.44 deaths/1000 student-years and from 1.28 to 0.44 treatment53. The accuracy of teacher deaths/1000 student-years, respectively. diagnosis was 75%. · The estimated cost of the treatment kit was approximately · A feasibility study of teachers providing early US$40 per school. Parents and communities were initially detection and management of presumptive requested to contribute 10% towards the cost of replacing the malaria in Ghana showed that 93% of kits, and by 2007 communities were paying 80% of the identified fever cases met the operational drug costs. definition of malaria and 75% of presumptive malaria cases were treated correctly54. · The estimated cost of providing each child with access to a treatment kit is US$0.38 per child per year. The estimated cost · A project in Malawi trained teachers to use of a child receiving a malaria treatment is US$2.30. Pupil Treatment Kits to treat suspected cases55 (see Box 5). · However, the government withdrew antimalarial treatment from Pupil Treatment Kits following the introduction While the potential of prompt, effective treatment by of ACTs. teachers has been investigated in pilot projects, there a number of challenges which have so far limited its Source: Pasha et al., 200355; and Temperley & Brooker (unpublished). widespread implementation: · Teacher motivation and ability. In both Ghana and Tanzania, teachers were satisfied with their new role; though expressing a clear desire for close and continued support from local health providers. The study from Ghana also found that the performance of teachers to correctly diagnose malaria declined after 5 months54, underscoring the need for regular refresher training. Other challenges included problems of teachers obtaining reliable histories from younger children, ensuring adherence to a 3 day drug regimen, high teacher turn over and need for retraining, and the disruption of teaching in class. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 13 · Correct diagnosis. Many of the signs and therefore for appropriate health education in schools on symptoms of malaria are non-specific, leading the dangers of malaria during pregnancy and the to unnecessary treatment of cases that are not benefits of attending antenatal health services, and of malaria. Confirmation by microscopy is thus, accessing LLINs and IPT. Many aspects of health preferable but may be impractical in many education and life skills teaching in schools are also schools. RDTs may be a practical alternative, relevant in reducing early and unplanned pregnancies. but are more costly and have to be stored at Specifically, schools can promote the following: specified temperatures. In Tanzania, teachers used thermometers to confirm abnormal body · Promoting the use of LLINs. Schools can promote temperatures in children complaining of fever53; increased utilization of LLINs among schoolgirls. however, provision of thermometers will increase Increasing net usage amongst adolescents ensures programme costs. that young mothers will be protected from malaria from the first day of pregnancy. · Accidental treatment of pregnant schoolgirls The use of antimalarial drugs should be avoided in · Promoting the attendance of antenatal health the first 3 months of pregnancy, because it can services. Schools can inform pupils of the benefits harm the growing foetus. Whenever pregnancy is of attending antenatal health services, such as suspected in a schoolgirl with fever, malaria availability of LLINs and IPT. However, teaching treatment should not be given; instead the schoolgirl should include both boys and girls, as boys are also should be referred to the nearest health unit for instrumental in deciding when to seek health care examination by a qualified midwife and appropriate services. These actions can thus, help overcome the treatment provided. The testing for pregnancy by main barriers to effective use of LLINs and IPT teachers is not advised. during pregnancy. · Antimalarial treatment using ACTs. · Febrile illness during pregnancy. Teachers can The recent introduction of ACTs poses an additional counsel pregnant schoolgirls suspected with febrile problem in identifying a uniform case management illness to attend a health facility for assessment by policy for schools. In particular, treatment guidelines a qualified midwife and to obtain appropriate and practices differ substantially between countries. antimalarial treatment and antenatal care. In Malawi, antimalarial treatment was withdrawn from Pupil Treatment Kits following the introduction It should be noted however, that only a minority of of ACTs. adolescent girls in Africa currently attend school, and there remains an important need to promote greater gender equity in secondary schooling. Prompt recognition and effective treatment of malaria among schoolchildren is essential. However, because of remaining operational Schools should promote the use of LLINs challenges, presumptive treatment by teachers among pregnant schoolgirls. Access to IPT is not currently recommended until its feasibility should be encouraged through antenatal and effectiveness has been further investigated. health services where both boys and girls Instead, teachers should be trained on the need to be informed of the benefits. recognition of danger signs and the need for Other malaria control methods prompt referral to a health facility, and schools should have a policy for referral. Other vector control methods for the prevention and Malaria and pregnant schoolgirls treatment of malaria are: · Personal protection measures other than Malaria is an important concern for pregnant schoolgirls LLINs. The use of window screens, repellents and since younger pregnant women often have a greater risk wearing long trousers and long sleeved shirts can of malaria parasitaemia, maternal anaemia with provide personal protection from host-seeking associated increased chance of dying, and delivering low mosquitoes at times where LLIN use is not practical, birth weight babies2,56,57. such as during early evening. Like LLINs, other personal protection measures are meant to stop However, adolescent girls are less likely to use antenatal adult mosquitoes from biting people. Boarding services and thus, less likely to access and use LLINs schools should be encouraged to provide netting and during pregnancy39. Studies in Kenya and Malawi also screens on dormitory doors and windows. show that less than half of adolescent mothers received the recommended dose of IPT58. There is a strong need 14 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa · Larval and environmental control. Breeding sites can be controlled through application of larvicides or introduction of predators that feed on mosquito larvae (e.g. fish). Alternatively, sites can be eliminated or changed to make them unsuitable for larval development or inaccessible to adult mosquitoes. Larval control aims at reducing human vector contact, thus, rendering conditions less conducive to disease transmission. During malaria campaigns in the 1950s and 1960s, there was considerable focus on mosquito breeding source reduction, where advice was given to schoolchildren to destroy potential mosquito breeding areas. This had demonstrable benefits for removal of nuisance mosquitoes ­ and important vectors of dengue and filariasis ­ but uncertain impact on malaria. Thus, the health benefits in promoting schoolchildren to destroy potential breeding sites in school grounds remain unclear. Boarding schools should be encouraged to provide netting and screens on dormitory doors and windows. However, the health benefits in promoting schoolchildren to destroy potential breeding sites in school grounds remain unclear. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 15 Skills-based malaria health education In general, skills-based health education aims to help children develop attitudes, knowledge and skills necessary to allow them to maintain and enhance their 4. Know how to help to reduce mosquito breeding sites. own health. With regard to malaria, this section provides information on key features of malaria health education 5. Know how to stop mosquitoes from biting people. (Bed nets based on current empirical evidence and presents impregnated with a mosquito repellant are the best examples of skills-based education programmes from means of protection.) different countries. Summaries of the evidence for skills- based malaria health education interventions discussed 6. Know that even if there are some holes in impregnated bed in this section are tabulated in Appendix 1. nets, they still offer protection. Skills-based malaria health education should promote 7. Know that treatment of malaria should begin immediately. the following: Any delay can make the disease more dangerous. · Attitudes such as responsibility for personal, family 8. Know that when malaria is treated it is essential that the full and community health, and building confidence to course of recommended medicine is taken. change unhealthy habits. 9. Know that children with fever need plenty of drinks to replace · Knowledge such as symptoms of malaria and the the water and salt they have lost through sweating. importance of seeking appropriate treatment as well as the importance of personal prevention, especially 10. Know that children with fever need to be kept cool, but not the use of LLINs. cold, to prevent their temperatures from rising too high. · Skills such as avoiding behaviours likely to cause malaria, encouraging others to change unhealthy Doing: Children should: habits, communicating messages about malaria and its prevention and control to families, peers and members of the community. 1. Help prevent mosquitoes from breeding, for example, by getting rid of stagnant water. Specific components of a skills-based health education approach to malaria control are detailed in Box 6 below. 2. Help prevent mosquitoes biting, for example, by making sure younger children use mosquito nets properly when they are available. BOX 6: 3. Help by calling attention to other children with health worker. 4. Help make sure that other children and family members take Components of a skills-based health the full course of treatment. education approach to malaria 5. Help look after children with fever and encourage them to eat control in schools extra food when they recover. Knowing: Children should: Feeling: Children should: 1. Know that malaria is serious and kills many people. 1. Feel confident about spreading messages about malaria control to their families and community. 2. Know that young children, old people and pregnant women are particularly vulnerable. 2. Feel that they share the responsibility with the rest of the 3. Know that malaria is spread by mosquitoes that breed in community for stopping mosquitoes breeding and biting. stagnant water and bite at night, spreading germs from infected to healthy people. Source: Child-to-Child Trust, 2007; and UNESCO, 2004 59, 60. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 17 Experience shows that malaria health education is most can include health clubs, film and drama effective when it is incorporated within a broad-based presentations and role playing. approach to health and relevant life skills. The following school pilot projects demonstrate the potential impact of · Skills-based health education should address skills-based malaria health education: both prevention and treatment of malaria. Typically, there is mismatch between the current · Results from a Kenyan study on the impact of school curriculum for malaria and the need for participatory health education indicated that for information amongst schoolchildren. Curricula often children receiving education, awareness of malaria rely on conveying pre-formulated information based increased, especially awareness of the importance of on biomedical issues, such as parasite species and control measures such as the use of ITNs61. transmission, without information about treatment. Rates of infection and morbidity also decreased. The curricula fails to teach treatment or medicine However, childrens knowledge about the need for use when in reality many schoolchildren actively self appropriate action when sick did not improve. treat for malaria, and this is done inappropriately in many cases66. · Another study in Kenya which used a community intervention trial, paired schoolteachers with health · Skills-based malaria health education should workers to provide schoolchildren with messages on build on existing beliefs and practices. Didactic ITN use. The messages were conveyed through teaching methods often used by teachers can be interactive learning methods including a 30-minute disempowering to those already equipped with play, small group work to discuss the play and a knowledge67. poster competition40. Although this increased childrens awareness of ITN, the messages were not · Malaria education programmes should provide always effectively transferred to parents at home. support to teachers. Teachers often lack appropriate knowledge about malaria and lack · An evaluation of an action-oriented and participatory confidence in using new participatory teaching health education in Western Kenya found that methods. Support for teachers can be achieved children acquired new concepts of health and illness through teacher training and the development of and took new responsibility for their own health and teacher guides. of others62,63. The programme was based on the Child-to-Child approach59,64 and included an · Malaria education programmes must take into action-oriented teaching approach that sought to consideration that childrens learning differs at develop childrens skills on: problem solving; various stages of development. The messages decision making; risk averting and positive actions. and teaching methods should be age-appropriate, targeting students and teachers at Early Child Many valuable lessons have also been learnt from skills- Development (ECD), and primary and secondary based HIV&AIDS education programmes65. These levels. For example, training ECD teachers to experiences show that behaviour change is possible if recognize signs and symptoms of malaria and to programmes focus on specific behavioural goals, and make appropriate referrals to the health facilities; provide sufficient training for teachers. Therefore, skills- older children can also be trained to recognize the based health education (e.g. for HIV&AIDS, and signs and symptoms of malaria and when to seek malaria) is most effective when it is supported by other appropriate treatment. reinforcing strategies such as consistent school health policies, effective referrals to external health service · Skills-based malaria health education should providers and links with the community. aim to empower both boys and girls. Teachers often treat boys and girls differently, viewing girls as While it is crucial for each country to identify the less bright, which influences their self opinions and content and approach of skills-based malaria health undermines their own self knowledge and actions. education, it is also important to consider the following This differential treatment of girls continues into issues: motherhood, and apparent when mothers present at a health facility67. Educating schoolgirls about the · Skills-based malaria health education should vulnerability of pregnancy and malaria, and the be embedded in the existing curriculum. dangers posed to their unborn child should be Knowledge about how malaria is transmitted, emphasized30. Schoolgirls can also be taught prevented and treated can be embedded in the about the care of their future children. In Ethiopia, science and health curriculum and integrated into teaching mothers to provide prompt treatment school health curricula including HIV&AIDS. To avoid resulted in a 40% reduction in under-five curriculum overload, activities that extend beyond mortality68; these skills can be instilled during the the classroom are also important. These activities school-age years. 18 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa · Schoolchildren can be important health change · Malaria skills-based health education tools agents in the wider community. Skills-based (see www.unesco.org/education/fresh). malaria health education through schools can help promote a community-wide understanding of malaria · A review of key concepts of skills-based health with particular emphasis on the need for community- education and life skills examples of best based control measures such as the use of ITNs. practice (see Studies in Kenya indicate how Child-to-Child, action- www.rollbackmalaria.org/docs/schoolhealthservices_malaria.pdf). oriented methods can enable schoolchildren to assist The Child-to-Child approach provides an additional their peers and parents to acquire health-related framework for health education programmes knowledge which lead to changed practices62. (see www.child-to-child.org). · Malaria education programmes should be consistent with the national school health policy and the overall malaria control strategy Skills-based malaria health education is most of the Ministry of Health. Such programmes effective in behavioural change when it is should focus on a few key strategic topics incorporated within a broad-based approach (see Box 7). to health and relevant life skills, and when supported by other reinforcing strategies such as school health policies, referrals to external health service providers and community links. BOX 7: Key strategies to be incorporated into a skills-based malaria health education programme · Clinical management: Provide children with the knowledge and skills about the early recognition of the signs and symptoms of malaria, and when to report to the health facility to access effective treatment. · LLINs: Promotion of LLIN use by schoolchildren and by their families, including priority groups such as under-fives and pregnant women. · Malaria in pregnancy: Promotion of universal access to ITNs and IPT with SP for pregnant schoolgirls accessible through health facilities. · Epidemic preparedness and response: Information on the need, purpose, method and timing of community-wide IRS in epidemic- prone districts. Source: Roll-Back-Malaria, 20057. The FRESH framework provides the context for effective implementation of quality skills-based malaria health education programmes (see www.freshschools.org /education.htm). Technical toolkits on health education have been produced by the agency partners in support of the FRESH framework, including: Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 19 How to get started? The Malaria Control in Schools toolkit provides ways in · Identifies the priority health and nutrition problems which policymakers/planners can design a malaria of school-age children; component in a wider school health programme. For · quantifies school enrolment, absenteeism, repetition, effective interventions several strategic steps should be and drop-out rates and identifies the major causes followed by policymakers/planners. These strategic of absence from school; steps are: 1. Conduct a situation analysis; · reviews current policies and guidelines on 2. Ensure stakeholder participation; school health; 3. Develop malaria control strategies which can be · identifies practicable, sustainable interventions integrated into existing programmes; that are likely to most improve childrens 4. Develop a national plan of action; health, nutrition and educational achievement; 5. Mobilize resources. · identifies major gaps in, and problems with, existing school nutrition and health services; Step 1: Conduct a situation and analysis · identifies issues requiring further investigation. A first activity in planning school health programmes, It is also important to define the burden of malaria which includes malaria control, is to conduct a situation among schoolchildren in the country, and especially how analysis. This can provide accurate and up-to-date this may vary in different parts of the country. This information on the current situation of malaria in information is critical for identifying suitable intervention schools in a country, including disease burden, policies strategies and to estimate the resources required for and previous experiences in implementation. school-based malaria control (see Box 8). A key technical resource is FRESH and its toolkit WHO, UNICEF and the World Bank also provide technical on conducting such a situation analysis6 and practical information on malaria control, including (see www.freshschools.org/Documents/FRESHandEFA- school-based interventions. Relevant information needed English.pdf). to help guide a school malaria programme is provided This resource provides guidance on by WHO30. Useful websites and relevant technical how to collect information which: resources are listed at the end of this toolkit. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 21 BOX 8: Country summary of malaria distribution ­ Angola Angola has a rich set of data on community-based P. falciparum Such maps help provide a framework to understand where different parasite prevalence data. These data provided by the Malaria Atlas intervention approaches might be implemented. It also provides an Project (MAP at www.map.ox.ac.uk/) has been assembled from surveys indication of the resources required in order to implement a national undertaken by various partners and projects since 198569. The data school malaria control programme. If no relevant information is were collected from randomly selected communities and individuals identified, it may be necessary to conduct a rapid school malaria survey, were examined using either blood slides or rapid diagnostic tests. whereby children in selected schools in different parts of the country The data were spatially located using combinations of Global Positioning are examined for malaria parasites. Systems, electronic gazetteers and other sources of longitude and latitude. Mapping these data within a Geographical Information System provides an evidence-based approximation of the prevalence of malaria infection across the country. Source: Hay et al., 200969. 22 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Step 2: Ensure stakeholder a possible common approach is developed. participation Box 9 offers an example of national dialogue and strategic planning for a response to malaria in schools. In many countries, there will be a number of different partners concerned with school health and malaria in schools. It is essential that malaria control programmes in schools foster representative and informed participation of all stakeholders. Thus, effective partnerships should be built with national and international NGOs, teacher unions, international agencies and research institutions. BOX 9: It is critical to create ownership of malaria control in National consensus and strategic schools at both local and national levels. Step 1 will planning for a school malaria help identify the districts in the country which are most at risk of malaria. Specific attention should be given to response in Kenya local communities in those districts at greatest risk to ensure their commitment. Meetings should be held with parents, teachers and community leaders to discuss their needs and to identify existing structures. Approaches to controlling malaria in schools in Kenya have to date been piecemeal, small-scale, and funded by international NGOs. Strong Finally, a national workshop should be held to discuss political support with clear recommendations for action and how government programmes can plan to include international funding are key to addressing such shortcomings, as well malaria in their school health programmes and to as for enhancing control efforts. In order to help achieve these features, develop effective programmes to help mitigate the a national stakeholder workshop on malaria control in schools was held possible impact of malaria on the education sector. in 2007, which had the following aims: Drawing on the situation analysis, the national stakeholder workshop should consider some of the · To review school health policies of the Ministries of Education following issues: and Health, and to revise the malaria component in the draft school health policy of the Ministry of Education, Science and · Consistency between policies and guidelines. Technology. To ensure success and sustainability, it is essential · To review the guidelines for school-based malaria that school malaria control programmes are interventions. consistent with and in support of the policies and guidelines of the local governments and their · To develop a work plan for implementing school-based Ministries of Education and Health. It is important malaria interventions within the context of the existing therefore to review relevant policies and guidelines School Health and Nutrition programme. and make suggested revisions to relevant policy documents and technical guidelines. The workshop brought together stakeholders to share their experiences, lessons learned and best practices, and sought to help achieve a · Learn from previous experiences. To avoid shared vision and a detailed and achievable action plan and budget implementing unsuccessful approach to malaria allocation. All stakeholders, including health and education officials from control in schools, it is important therefore to review national and local levels, representatives from national and international the experiences, successes and lessons learnt from organizations and NGOs, and teachers, were represented and who previous efforts in the control of malaria in schools. actively participated. The main outputs of the workshop included: These experiences could include programmes implemented by the government or local NGOs. A · Suggested revisions to the malaria sections in the draft number of lessons can be leant from the experience school health policy. of developing skills-based education for HIV&AIDS. · Suggested revisions to the guidelines for school-based · Harmonized approach to malaria control. It is malaria interventions. essential that ministries of education and health as well as local donor partners propose an integrated · Work plan for implementing school directed malaria approach to malaria control in schools, rather than interventions. implementing separate programmes in parallel. It is important to have regular communication and A copy of the final workshop report is provided in Appendix 2. collaboration between various stakeholders and that Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 23 Step 3: Develop malaria control messages should be incorporated into existing life skills strategies which can be messages. integrated into existing The following strategies are only recommended in programmes high transmission settings, where the prevalence of P. falciparum infection is 20% or greater: In recent years, the education sector in many African · School-based delivery of IPT or presumptive countries has come to play an increasingly important treatment to schoolchildren; again this could role in the health and nutrition of school-age children. be coordinated with deworming. Schools provide a conducive environment for the · Health education to encourage pregnant provision of simple health services to many children at schoolgirls to access IPT through antenatal the same time, including school feeding, micronutrient services. supplementation and deworming programmes. School- Step 4: Develop a national plan based malaria control will have its full impact when delivered within an integrated school health programme. of action Information obtained from the situation analysis (Step 1) and stakeholder meetings (Step 2) will Government actions are typically implemented on a provide a good sense of what is currently being done. sectoral basis. It is therefore essential that the action plans for the school response to malaria are included The same suite of school-based strategies will not be within the relevant national sectoral plans. Actions relevant everywhere. Life skills messages, about the use involving curriculum change, teacher training and of LLINs, the early recognition of malaria and how to classroom activities should be included within the access prompt treatment, should be part of the health national education sector plan. Procurement of education in all transmission settings, whereas IPT, if medicines, training of health personnel to provide proven to be effective, is likely to be relevant only in youth-friendly services, and training of teachers by high transmission areas. In epidemic-prone settings, by health personnel or school visits by health teams contrast, neither LLINs nor IPT would be appropriate, should be included in the national health sector plan. instead schools may provide useful sentinels for In practice, the most effective way to implement this epidemic detection and strengthening of drug supplies is to hold a joint meeting of the relevant health and at health facilities. education policymakers to decide the division of responsibilities between the two sectors, and then for Examples of good practice have been documented each sector to develop its own plan using the normal earlier in this toolkit, including: planning processes for each ministry. · The promotion among schoolchildren of ITN In developing this plan, realistic projections of costs use in Kenya ­ Box 3. associated with the various strategies are clearly necessary. · Presumptive treatment of suspected malaria in schools in Malawi ­ Box 5. The following malaria components of an integrated school health programme are recommended as possible strategies which should be considered in all malaria transmission settings: · distribution of LLINs through schools; · health education to promote the use of LLINs; · health education to promote early recognition of malaria and appropriate referral to health facilities; and · health education to encourage pregnant schoolgirls to access diagnosis and early treatment through antenatal services. Distribution of LLINs in schools could occur on the same day as deworming is provided. While health education 24 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Step 5: Mobilize resources Resources too are likely to have separate sectoral BOX 10: origins. The costs of treatments, LLINs and health personnel actions are the responsibility of the health Education for All-Fast Track Initiative sector, which is likely to already have processes in place (EFA-FTI) education sector plan for mobilizing these resources for younger children. The biggest challenge is to identify resources for the preparation education sector to ramp up activities which are seen as health-related. There is a need for an initial investment in ­ in-service teacher training, and in materials The FTI seeks to accelerate country progress toward the goal of development and production ­ which might Universal Primary Completion (UPC) by supporting credible and appropriately be supported by external resources. Once sustainable education sector plans. In general, a country education teachers have been trained in this way the process can sector plan (ESP) would address key constraints to accelerating UPC in thereafter be supported at marginal cost by the normal the areas of policy, data, capacity, and financing and align primary pre-service training mechanisms. Countries may wish to education priorities with those for pre-school, secondary, tertiary, and include funding for the education sector within their non-formal education. The ESP is developed or updated by the national proposal for malaria control to The Global Fund Government in consultation with the Local Education Group. An ESP that to Fight AIDS, Tuberculosis and Malaria. is a credible plan will be anchored in the countrys existing circumstances and implementation capacities, while at the same time Where countries have education sector alliances of pushing those boundaries by strengthening policies and making the development partners, these alliances can provide a first changes needed so as to seriously enhance the capacity to ensure point of approach for an initial investment of resources. quality education to all. This process is facilitated if a national education Sector- Wide Approach (SWAp) is already established or if the It is essential that the ESP be fully costed and clearly embedded into country is eligible to access resources from the the countrys overall poverty strategy, but also in terms of other policies Education for All ­ Fast Track Initiative (EFA-FTI) (see and strategies around public service reform, decentralization, gender Box 10). In both cases, however, it is essential that the and other cross-cutting issues such as: HIV&AIDS, equity, inclusion, and malaria response is an established component of the learning outcomes, school health, malaria control, and school feeding. education sector plan. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 25 Additional resources As well as the information included in this toolkit, there are a number of additional resources that provide information on malaria, health education and school health. Malaria ­ general WHO WHO-Southern Africa Malaria Control Programme. Information for Action Leaflet, Southern Africa Malaria Update, Malaria Control in Schools. Available at: www.doh.gov.za/issues/malaria/red_reference/SAMC/publications/iec1.pdf Focusing Resources on Effective School Health. A FRESH start to improving the quality and equity of education, World Education Forum 2000, Dakar, Senegal. Available at: www.schoolsandhealth.org/sites/fresh/Documents/FRESHandEFA-English.pdf Diagnosis and treatment Roll Back Malaria Strategic framework for scaling up effective malaria case management. Available at: www.rollbackmalaria.org/partnership/wg/wg_management/docs/framework.pdf The use of Rapid Malaria Diagnostic Tests, Second Edition. Available at: www.wpro.who.int/health_topics/ malaria/ Changing malaria treatment policy to Artemisinin-based Combinations: An implementation guide. Available at: www.rollbackmalaria.org/docs/mmss/act_implementationguide-e.pdf WHO Guidelines for the treatment of malaria. Available at: http://malaria.who.int/docs/TreatmentGuidelines2006.pdf Indoor residual spraying Roll Back Malaria (RBM) Insecticide-treated mosquito net interventions: A manual for national control programme managers. Available at: http://rbm.who.int/cmc_upload/0/000/016/211/ITNinterventions_en.pdf WHO Indoor residual spraying: Use of indoor residual spraying for scaling up global malaria control and elimination. Available at: http://malaria.who.int/docs/IRS-position.pdf Insecticide-treated nets and long-lasting insecticidal nets Lengeler, C. (2006). "Insecticide-treated bednets and curtains for preventing malaria." Cochrane Database Systematic Reviews (2): CD000363. A comprehensive review of published studies. Roll Back Malaria Factsheet on insecticide-treated mosquito nets. Available at: www.rollbackmalaria.org/cmc_upload/0/000/015/368/RBMInfosheet_5.pdf WHO Scaling-up insecticide-treated netting programmes in Africa: A strategic framework for coordinated national action, Second Edition. Available at: www.rollbackmalaria.org/partnership/wg/wg_itn/docs/WINITN_StrategicFramework.pdf Insecticide-treated materials. Available at: www.who.int/malaria/publications/atoz/updatelln_2/en/ index.html Malaria in pregnancy Roll Back Malaria Factsheet on malaria in pregnancy. Available at: www.rollbackmalaria.org/cmc_upload/0/000/015/369/RBMInfosheet_4.htm WHO Pregnant women and infants. Available at: www.who.int/malaria/high_risk_groups/pregnancy/en/ index.html Health education Child-to-Child Trust Child-to-Child Trust (2005). Children for Health. Children as partners in health promotion. Child-to-Child Trust (2007). Child-to-Child A resource book. Child-to-Child activity sheets. FRESH Malaria. Available at: www.unesco.org/en/education Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 27 Additional resources (cont) WHO Skills for health: Skills-based health education including life skills: An important component of a Child-Friendly/ Health-Promoting School. Information Series of School Health. Document 9. Available at: www.who.int/school_youth_health/media/en/sch_skills4health_03.pdf School health FRESH UNESCO, UNICEF, WHO, World Bank (2001). Focusing Resources on Effective School Health; A FRESH start to enhancing the quality and equity of Education for All. World Bank, Washington DC. Available at: www.freshschools.org/Documents/FRESHandEFA-English.pdf PCD Partnership for Child Development (1999). A situation analysis ­ A Participatory Approach to Building Programmes that Promote Health, Nutrition and Learning in Schools. Available at: www.schoolsandhealth.org/Documents/A%20Situation%20Analysis%20- %20A%20Participatory%20Approach%20to%20Building%20Programmes1999.pdf Drake L.J., Maier C., Jukes M., Patrikios A., Bundy, D.A.P., Gardner A. and Dolan, C. (2002). School age children: Their health and nutrition. SCN News (25). Available at: www.schoolsandhealth.org/documents/school-age%20children%20-%20their%20nutrition%20and%20health.pdf 28 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Useful websites UNICEF With the aim of improving global child health UNICEF supports various activities and programmes on malaria The following are useful websites of organizations that prevention and control. UNICEF is involved in various support malaria control, health education and school global partnerships in particular the RBM initiative (see health. WHO below). FRESH Malaria www.unicef.org/health/index_malaria.html FRESH provides a global framework for school health programmes and provides education policymakers and WHO planners with information on how best to identify and effectively address health and education problems. The An organization responsible in providing leadership; FRESH framework also captures best practices from technical support; evidence-based policies and research; programme experiences for the design and monitoring and evaluation; and setting standards on implementation of effective school health and nutrition global health issues. WHO has various programmes and programmes, including those addressing malaria. activities on malaria prevention and control and school health programmes. www.freshschools.org/ http://portal.unesco.org/education/en/ev.php- Global Malaria Programme URL_ID=35181&URL_DO=DO_TOPIC&URL_SECTION=201.html www.who.int/malaria Schools and Health Global School Health Initiative www.who.int/school_youth_health/gshi/en/ The Schools and Health website is administered by the Partnership for Child Development (PCD). An The World Bank organization committed to improving the education, health and nutrition of school-age children and youth in An organization that provides technical and financial low income countries. It helps countries and assistance to developing countries which supports international agencies turn the findings of evidence- various programmes for the control of malaria. based research into national interventions that benefit children worldwide. It also acts as a resource centre on Malaria education, health and nutrition of school-age children www.worldbank.org/malaria and on school health programmes, including information on malaria. Global Strategy and Booster Programme http://go.worldbank.org/GQXZEC5C60 www.schoolsandhealth.org Child-to-Child Trust An international organization that helps to promote the health, well-being and development of children and young people, their families and their communities through a child-to-child rights-based approach. Such an approach can be usefully adopted to disseminate messages about malaria prevention and control to school children and their families. www.child-to-child.org Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 29 Glossary Acidosis: A disturbance of the body acid-base balance pregnancies. It is more common in non-immune in which there is excessive acidity of the blood, populations with increased incidence during arising from abnormal metabolism (as in severe epidemics of malaria. Common signs of congenital malaria). malaria are when the newborn shows signs of anaemia, fever, jaundice, difficulties in feeding Anaemia: A decrease in the number of red blood cells and irritability. and quantity of haemoglobin. Malaria causes anaemia through rupturing of red blood cells Dichlorodiphenyltrichloroethane (DDT): A synthetic (RBC) as well as through decreased RBC insecticide which is highly toxic to insects. Until production. the 1990s, DDT was the most widely used insecticide in public health. However, because of Antibody: A protein produced by the immune system in its widespread use, resistance in insect responses to the introduction of a substance populations developed, decreasing its recognised as foreign. effectiveness. There were also concerns over DDT poisoning both wildlife and the environment; Artemisinin-based Combination Therapies (ACTs): there is now a worldwide ban on the agricultural Treatments for uncomplicated falciparum malaria use of DDT. that combine several antimalarial drugs, one of which is a derivative of artemisinin. The most Epidemic: A rapid outbreak of a disease through a common artemisinin derivatives used in ACTs are community in which the disease is normally artesunate and artemether. The drugs commonly absent or present at low levels. used in combination with the artemisinin derivative include mefloquine, lumefantrine, and Epidemiology: The study of the distribution and amodiaquine. ACTs are now the recommended determinants of infection and disease in first line of treatment for malaria. populations. Case management: A prompt, comprehensive and Haemoglobin: Protein in red blood cells which carries effective treatment and provision of supportive oxygen. Haemoglobin gives blood its red colour. care. For malaria, this usually involves accurate diagnosis followed by treatment with an effective Helminths: Parasitic worms found in the intestinal antimalarial drug. tract, urinary tract or in the blood of humans. Cerebral malaria: A complication of Plasmodium Immunity: The bodys ability to control or lessen a falciparum clinical malaria in which infected red malaria attack with antibodies and other blood cells obstruct blood circulation in the small protective measures developed in response to blood vessels in the brain. Cerebral malaria often previous malaria attacks. Immunity minimizes the results in coma and sometimes death. clinical symptoms of malaria. Chemoprophylaxis: The regular (daily or weekly) Incidence: The number of new cases of a disease administration of drugs in therapeutic doses over occurring within a specified period. a sustained period of time to all individuals, irrespective of infection status, to prevent Indoor residual spraying (IRS): Spraying long- infection or progression of infection to illness. lasting insecticide on the indoor walls and eaves of houses in order to kill resting mosquitoes that Clinical malaria: An acute febrile illness with a varying rest indoors following biting humans. of clinical symptoms. The two major syndromes of clinical malaria are cerebral malaria and malarial Insecticide-treated net (ITN): A fine meshed net anaemia. that has been treated with a long-lasting insecticide hung over a bed to protect sleepers Cognition: Conscious mental activity that includes from insect bites. perceiving, thinking, reasoning, judging, problem solving, and remembering. Intermittent preventive treatment (IPT): The periodic mass administration of a full therapeutic Congenital malaria: Where the malaria infection course of an antimalarial, irrespective of infection spreads through the placenta to the foetus. status. Congenital malaria is very rare affecting <5% of Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 31 Glossary (cont) Larvicides: An agent for killing insect larvae. In the Plasmodium: The group of parasites that includes all of case of malaria, these are mosquito larvae. the malaria parasites affecting humans and other Long-lasting insecticidal net (LLIN): A bed net animals. which is manufactured with long-lasting insecticide directly incorporated into its fibres, Prevalence: The proportion of a population that is hung over a bed to protect sleepers from affected with a particular disease at a given time. insect bites. Rapid diagnostic test (RDT): A rapid method of Maternal anaemia: The occurrence of anaemia during determining whether an individual has a certain pregnancy. The main mechanism by which malaria disease. For example, malaria RDTs detect malaria causes anaemia in pregnancy is the destruction of antibodies present in the bloodstream. red blood cells. Resistance: The ability of the parasite or insect Microscopy: The technical use of microscope to view populations to tolerate doses of a drug or samples. When performed in optimal conditions, insecticide which would prove lethal to the microscopy remains the crucial methodology for majority of individuals in a normal population of the detection of malaria parasites in the blood. the same species. Morbidity: The number of cases of a disease during a Stable malaria transmission: A situation where the specific period of time. prevalence of malaria infection is persistently high and transmission is relatively insensitive to Mortality: The number of deaths in a population during environmental/climatic changes. High levels of a specific period of time. immunity develop within the population due to regular exposure to malaria parasites. Neurological impairments: Diminished capacity of the nervous system is limited or impaired with Unstable (or epidemic-prone transmission): A difficulties exhibited in the use of memory, the situation where malaria varies greatly in space control and use of cognitive functioning, sensory and time, often in relation to environmental/ and motor skills, speech, language, or basic life climatic factors. Immunity is low and there is a functions. Cerebral malaria can occasionally cause propensity for epidemics to occur. children to be left with neurological impairments, including partial body paralysis, speech disorders, Vector: An agent that transmits disease from one host blindness, epilepsy and behavioural disorders. to another. For example, the mosquito that transmits the malaria parasite. Parasitaemia: The presence of parasites in the blood with or without clinical symptoms. Permethrin: A synthetic form of pyrethrum, an effective insecticide which kills insects. It is obtained from the flowers of chrysanthemum plants. 32 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa References 1. Bundy DAP, Shaeffer S, Jukes M, Beegle K, 12. Fast-Track-Initiative: Quality Education for All Gillespie A, Drake L, Seung-heem FL, Hoffman A- Children: Meeting the Challenge. Washington DC: M, Jones J, Mitchell A, Wright C, Barcelona D, World Bank; 2007. 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Hygiene 1988, 91:55-59. 68. Kidane G, Morrow RH: Teaching mothers to 77. Onyango-Ouma W, Aagaard-Hansen J, Jensen BB: provide home treatment of malaria in Tigray, Changing concepts of health and illness Ethiopia: a randomised trial. Lancet 2000, among children of primary school age in 356:550-555. Western Kenya. Health Education Research 69. Hay SI, Guerra CA, Gething PW, Patil AP, Tatem 2004, 19:326-339. AJ, Noor AM, Kabaria CW, Manh BH, Elyazar IR, Brooker S, Smith DL, Moyeed RA, Snow RW: A 78. Pullan RL, Bukirwa H, Staedke SG, Snow RW & world malaria map: Plasmodium falciparum Brooker S: Plasmodium infection and its risk endemicity in 2007. PLoS Medicine 2009, factors in eastern Uganda. Malaria Journal 6:e1000048. 2010 (in press). 70. Leenstra T, Phillips-Howard PA, Kariuki SK, Hawley WA, Alaii JA, Rosen DH, Oloo AJ, Nahlen BL, Kager PA, ter Kuile FO: Permethrin-treated bed nets in the prevention of malaria and anemia in adolescent schoolgirls in Western Kenya. American Journal of Tropical Medicine and Hygiene 2003, 68:86-93. 36 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Appendices 37 APPENDIX 1: Tabulated summaries of studies investigating the impact of school-based malaria control School-based ITN interventions Study Population Methodology Evaluation Results 70 Adolescent schoolgirls, Intervention: Community Outcome(s): Hb Decreased prevalence of Kenya randomized-controlled trial. concentration. Parasitaemia. all-cause anaemia and an Age range: 12 to 18 years ITNs were randomly Survey: Cross-sectional increase in haemog-lobin Transmission setting: distributed to half the villages surveys performed in 28 concentrations. No effect High Stable in the area. selected schools. on malaria prevalence or Follow up: 2 years density was recorded. 41 Burundi communities Intervention: Health Outcome(s): Net coverage. Increased net usage and Age range: community promotion through health care Rates of parasitaemia in decreased parasitaemia in Transmission setting: facilities, schools and local under 9 year olds under 5 year olds. High Stable administration were called on Survey: Cross-sectional to promote bednets, which surveys. were being sold below the market price. There is no methodology on how the promotion in schools was done. Follow up: 2 years 40 Primary schoolchildren Intervention: Randomized- Outcome(s): Knowledge. 2,040 children (54%) had in Kilifi, Kenya controlled evaluation using Survey: In a sample of six nets at home. Responses Age range: 5 to 18 years schoolchildren as a channel schools, questionnaires were to the pre- and post-test Transmission setting: for communication to the given to random samples of questionnaires showed High Stable surrounding community. children immediately before improvements in Morning programme and after the teaching knowledge scores from incorporating the delivery of programme and to a third 58% to 90% by the the bednet, messages in the sample 3 months later. pupils and a level of 80% form of a 30-minute play, Parent Teachers' Association with the 3 month follow- group work on the play and meetings were also held. ups. activities (i.e. a poster competition and a survey form to take home). Follow up: 3 months 37 190 Kenyan boarding Intervention: Comparative Outcome(s): Parasitaemia. A reduction in attack school students trial group (1) slept under Survey: Any child reporting rates of: 97.3% for the Age range: 6 to 18 years nets (2) received proguanil sick was sent to dispensary net group and 77.1% for Transmission setting: hydrochloride daily according where nurse took a blood the proguanil treatment High Stable to weight (3) received slide for malaria and every 2 group. placebo tablets daily. All were weeks thick blood film taken treated for malaria at start from all study participants. to clear any parasitaemia. Distribution of tablets was supervised by teachers. Follow up: School term 38 Appendices School-based chemoprophylaxis Study Population Methodology Evaluation Results 27 587 schoolchildren, Intervention: Randomized Outcome(s): Parasitaemia, No differences in 4 schools, Southern double-blind, placebo- Hb levels, and Educational language and math Sri Lanka controlled clinical trial. attainment. scores between groups in Age range: 6 to 12 years Children in each school Survey: Thin blood smears pre-intervention. During Transmission setting: received either (1) taken at start and end of intervention, malaria High Unstable chloroquine tablet or (2) study Language and incidence rate dropped placebo tablet after a meal mathematic scores. End of (55%) and absenteeism under supervision by teacher term examination marks for decreased (62.5%) in or researcher. language and maths in 1998 treatment group. In post- Follow up: 1 year and (pre-intervention) and 1999 intervention, treatment 4 months (post-intervention). groups scored 26% higher in language and maths compared to placebo group. 71 392 suburban primary Intervention: Cohort study. Outcome(s): Parasitaemia, Compliance 96.3% a schoolchildren, Weekly Maloprim haematological responses month. Clinical malaria Mozambique chemoprophylaxis or a and immune responses significantly higher in Age range: 7 to 12 years placebo. A health assistant Survey: Daily monitoring for placebo group (279 per Transmission setting: was permanently placed at malaria symptoms; cross- 1000/year vs. 36 per High Stable the school. Parasitological sectional haematological 1000/year, p<0.0001). and clinical examinations surveys every month. In the experimental were undertaken throughout group weekly the study. chemoprophylaxis Follow up: Children were reduced parasite rate treated for 1 year but during the rainy season followed prospectively for from 43% to 4% and 2 years to observe any during the dry season rebound effect. from 18% to 0%. No signs of a rebound effect after the 1 year follow up. 37 190 Kenyan boarding Intervention: Comparative Outcome(s): Parasitaemia. A reduction in attack school students randomized-controlled trial. Survey: Any child reporting rates of: 97.3% for the Age range: 6 to 18 years (1) slept under nets (2) sick was sent to the net group and 77.1% for Transmission setting: received proguanil dispensary where the nurse the proguanil treatment High Stable hydrochloride daily according took a blood slide for malaria group. to weight (3) received and every 2 weeks thick placebo tablets daily. All were blood films were taken from treated for malaria at start to all study participants. clear any parasitaemia. Distribution of tablets was supervised by teachers. Follow up: School term. 72 166 suburban primary Intervention: Randomized- Outcome(s): Parasitaemia. Incidence rate per person schoolchildren, controlled trial. Survey: Blood was taken year 1.08 in placebo vs. Mozambique. Chemoprophylaxis with every 2 weeks. 0.00 in the treatment Age range: 7 to 12 years weekly maloprim or placebo. group. Transmission setting: Follow up: 17 weeks High Stable Appendices 39 School-based chemoprophylaxis continued... Study Population Methodology Evaluation Results 73 80 primary schoolchildren, Intervention: Randomized- Outcome(s): Parasitaemia. Both chloroproguanil Tanzania. controlled trial. Survey: Thick and thin blood taken twice a week and Transmission setting: Chemoprophylaxis, a curative films taken at regular proguanil taken daily High Stable dose of mefloquine for all, intervals. were found to be then prophylaxis or placebo efficacious. Children in (1) proguanil 100mg daily (2) the placebo group were chlorproguanil 20mg twice a re-infected within 10 week (3) placebo. weeks compared to no Follow up: 13 weeks infections in the two treatment groups. 74 118 schoolchildren, Intervention: Randomized- Outcome(s): Parasitaemia. P.falciparum attack rate Kenyan coast. controlled trial. Chemoprop- P.falciparum genotypes significantly decreased. Age range: 6 to 10 years hylaxis. Antimalarial drugs Survey: Thick blood films Transmission setting: given as curative dose at from all participants every 2 High Stable start of the study then weeks. randomly allocated to treatment group chloroproguanil (20mg weekly) or a placebo group. Follow up: 20 weeks 75 105 primary schoolchildren Intervention: Randomized- Outcome(s): Clinical signs, Symptomatic and from 4 schools in Kenya controlled trial. Chemoprop- parasitaemia. asymptomatic malaria Age range: 9 to 14 years hylaxis with daily (1) Survey: Weekly blood infections decreased. Transmission setting: primaquine (2) doxycycline smears from each participant High Stable (3) proguanil plus weekly and clinical signs recorded. Chloroquine (4) vitamin plus weekly mefloquine or (5) vitamin tablets. Follow up: 11 weeks School-based IPT interventions Study Population Methodology Evaluation Results 26 6,735 schoolchildren, in Intervention: Cluster- Outcome(s): Hb levels. Both per protocol and 30 primary schools, randomized placebo- Prevalence and intensity of intention-to-treat Western Kenya controlled trial. IPTc. Schools P. falciparum. Class-based analyses show that IPT Age range: 5 to 18 years were randomly allocated to attention function tests and with SP+AQ resulted in Transmission setting: an intervention (SP+AQ) or knowledge tests. 48% reduction in rates of High Stable placebo: IPT was given 3 Survey: Cross-sectional anaemia and 98% times per year, once each surveys in March 2005 and reductions in prevalence term. Mass deworming was 2006. of asymptomatic infection carried out every 6 months in and anaemia all schools. Follow up: 12 months. 50 296 schoolchildren, in one Intervention: Individual- Outcome(s): Hb levels. IPT resulted in lower village, Mali randomized trial. Children Prevalence and intensity of rates of anaemia (SP+ Age range: 6 to 13 years were randomly allocated to P. falciparum. AS, 17.7%; AQ+AS, Transmission setting: three arms: (1)IPT using Incidence of clinical malaria. 16.0%; and vitamin C, Moderate and seasonal SP+AS; (2) IPT using Survey: Monthly follow-up 29.6%) and fewer AQ+AS; and (3) Vitamin C. visits in January 2008 and malaria attacks (SP+ AS, IPT was given twice, 2 May 2008. 18; AQ+AS, 30; and months apart. vitamin C, 54). Follow up: 8 months. 40 Appendices Presumptive treatment by teachers Study Population Methodology Evaluation Results 54 Schoolchildren from 12 Intervention: Exploratory Outcome(s): Treatment Found if teachers are primary schools, Ghana (phase 1) and quasi- accuracy. Parasitaemia. willing partners they can Age range: 5 to 18 years experimental (phase 2) Survey: Thick blood smears diagnose malaria. Transmission setting: intervention trial. In Phase 1, and teachers records. Pre-packaging malaria High Stable treatment by teachers. drugs increases Trained teachers (health and distributors and users headteachers) for 5 days to compliance. diagnose presumptive malaria and treat with chloroquine (trained to recognize symptoms but not to use a thermometer). In phase 2, tested pre- packaging on treatment and user compliance. Follow up: 4 years 53 1,377 primary Intervention: School health Outcome(s): Parasitaemia. Among children who schoolchildren in 11 programme. Treatment by Treatment records fulfilled the algorithm Tanzanian schools teachers. In 3 day seminars Survey: Thick blood films criteria, 75% were Age range: 7 to 15 years the headteacher and the used to validate teacher parasite positive. Transmission setting: health teacher from each diagnosis (positive or With little training it was High Stable school were trained to negative parasitaemia). feasible for teachers to recognize and record malaria Malariometric surveys carried make presumptive symptoms and pupils out annually from 1995 to diagnoses of malaria. temperatures using an oral 1997. All children treated digital thermometer. They completed the treatment were trained in the course over 3 days. dispensing of supervised chloroquine delivery for pupils with presumptive malaria. Teachers were also trained in preparation of thick blood films using finger prick blood. Follow up: 2 years 55 Schoolchildren in 101 Intervention: School health Outcome(s): Malaria Malaria-specific mortality Malawian schools and nutrition intervention. mortality. rates dropped from 1.28 Age range: 5 to 18 years Teacher treatment with Survey: The malaria specific to 0.44 deaths/1000 Transmission setting: treatment kits. Save the mortality rates were student-years. Overall High Stable children ­ USA, dispensed calculated for 3 years before mortality rates dropped Pupil Treatment Kits to the intervention and for from 2.2 to 1.44 33 schools. Teachers and 2 years after its introduction. deaths/1000 student- community members had a years. 3-day treatment kit orientation session and then two teachers from each school were trained for 5 days to diagnose malaria on the basis of symptoms and to treat with SP. Posters, theatre groups and community meetings advocated treatment kits. Follow up: 2 years Appendices 41 Skills-based malaria health education Study Population Methodology Evaluation Results 76 10 rural secondary schools, Intervention: Quasinon before Outcome(s): Knowledge. After intervention, there Nigeria and after experimental design. Survey: 10 secondary was significantly higher Age range: 5 to 18 years Health education in schools. schools in two clusters (five scores in the intervention Transmission setting: Teachers were provided a 4-day in each) formed experimental group compared to High Stable orientation course to carry out and control groups. Self- controls for knowledge of health education to pupils in the completed questionnaire cause, prevention and control of malaria, testing knowledge given as treatment. No information schistosomiasis, dracunculiasis pre-test (exp n=632, controls was provided on the and onchocerciasis using n=678) and post-test (exp. nature of the measuring demonstrations, story telling, n=343 and control n=234). instrument or what was role playing and visual aids. considered as correct Follow up: 2 years knowledge. 40 Primary schoolchildren in Intervention: Randomized- Outcome(s): Knowledge. 2,040 children (54%) had Kilifi, Kenya controlled community Survey: In a sample of six nets at home. Responses Age range: 5 to 18 years intervention trial. Using schools, evaluation to the pre- and post-test Transmission setting: schoolchildren as a channel for questionnaires were given to questionnaires showed High Stable communication to the random samples of children improvements in surrounding community and immediately before and after knowledge scores from other schoolchildren. Morning the teaching programme and 58% to 90% by the programme incorporating the to a third sample 3 months pupils and a level of 80% delivery of the bednet, later. Following completion of with the 3 month follow- messages in the form of a 30- the programme meetings ups. minute play, group work on the were held with the play and activities (i.e. a poster committees of Parent competition and a survey form Teachers' Association (PTA) in to take home). six of the schools. Follow up: 3 months 61 200 primary Intervention: Experimental Outcome(s): Knowledge, No significant change schoolchildren, Kisumu, cohort study. Health education Attitudes and Practices, occurred on the Western Kenya in schools. Pupils attended a 45- Parasitaemia, self reported knowledge of the disease Age range: 7 to 18 years 60 minute educational session morbidity. between the groups after Transmission setting: using LePSA approach. Survey: An experimental 3 months. Authors claim High Stable Follow up: 3 months cohort of 100 pupils positive improvement in compared with 100 controls. attitudes, sickness and Survey at start and repeated absenteeism rates but at end of 3 months. data presented were unclear with no significance test results. 77 40 primary schoolchildren Intervention: Action-oriented Outcome(s): Knowledge. Qualitative results in rural Kenya health education intervention. Survey: In-depth interview suggest that improved Age range: 10 to 15 years Health education for select before and after intervention. knowledge resulted in Transmission setting: children to act as Inclusive of drawing and behavioural changes and High Stable communicators. Teachers writing methods. that children can be used attended a 2-day training as agents for change workshop in action-orientated through health education. teaching methods. Forty NB: This study had no children from two schools were control group. then selected to partake in a 2-month health education intervention where they were educated by teachers to understand malaria and diarrhoea. The study participants were then enrolled as communicators for the community. Follow up: 14 months 42 Appendices APPENDIX 2: Report of a national stakeholder's workshop on malaria in schools, Kenya, 2007 Ministry of Education and Ministry of Health Republic of Kenya National Stakeholder's Workshop on Malaria in Schools At the Kenya Institute of Education March 15th-16th 2007 43 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Executive Summary A National Stakeholder's Workshop on Malaria in The workshop managed to accomplish the three Schools was held at the Kenya Institute of Education objectives with the main outputs being: on 15th -16th March, 2000. The objectives of this workshop were to: 1) Suggested revisions to the malaria sections in the draft school health policy; 1) Review and revise the malaria component in 2) suggested revisions to the guidelines for the draft school health policy; school-based antimalaria interventions; and 2) review and revise the guidelines for school- 3) a tentative work plan for implementing school based malaria interventions; and directed antimalaria intervention. 3) develop a work plan for implementing school- based malaria interventions within the context of the existing School Health and Nutrition (SHN) programme. 44 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Background Development Communications Ltd and the KIE gave presentations on their programmes and experiences. Effective malaria health education and interventions These presentations formed a basis for identifying and which can be delivered to schoolchildren through schools discussing crucial interventions that work and need to currently exist, but there remains a lack of consistent be considered for inclusion into the action plan. In policy guidance on how these can be implemented in addition, the presentations shed light on the existing practice. There are also a number of potential strategies gaps and challenges that need to be addressed. From of unproven effectiveness thus, requiring further these discussions, the participants identified possible discussions and research. Recent funding has been interventions and strategies for school directed provided by EPDF of the World Bank to accelerate the antimalaria interventions. Below is a summary of the education sector response to malaria. This work aims to salient issues that emerged from the presentations and provide both policy and technical guidance on how the the ensuing discussions. education sector can respond to malaria and support an initial group of countries, including Kenya, to begin the · The role of the education in the control of process of developing scaled up school-based malaria malaria was well appreciated. interventions within the Malaria Booster Programme of · There are a number of players involved in the World Bank. school health but their activities are uncoordinated. Each school malaria programme must be tailored to its specific context, considering variations in malaria · A number of malaria-related skills-based health epidemiology, existing infrastructure and national policy. education materials exist but these are not Before a programme can be designed, a clear uniform and there is an urgent need to understanding is needed of the school health and standardize the Information, Education and educational policy and previous experience. In Kenya, Communication (IEC) materials across the there are a number of small scale programmes which country. provide examples of promising practice that can provide · There is a need for clear, simple messages to the basis of the development of more specific guidance develop the necessary life skills related to and guide large-scale implementation. For this reason, it malaria recognition, management and was deemed necessary to hold a national workshop to prevention. allow relevant stakeholders together to share their experience, lessons learned and best practices. It was · These messages should be consistent with the against this background that the Ministry of Education strategy of the national malaria control (MoE) invited relevant stakeholders to a 2 day workshop programme of the Ministry of Health (MoH). at the Kenya Institute of Education (KIE), which had the · A draft child health policy of the MoH is following aims: available but requires input from the MoE. 1) Review school health policies of the Ministries of · There is a need for improved communication Education and Health, revise the malaria and collaboration between the schools and component in the draft school health policy of health facilities at local levels. the Ministry of Education, Science and · A number of lessons can be learnt from the Technology. experience of developing skills-based 2) Review the guidelines for school-based malaria education for HIV&AIDS. interventions. 3) Develop a work plan for implementing school- · It was recognized that malaria is a complex based malaria interventions within the context of disease and there is a need to require careful the existing SHN programme. deliberation and wider discussion before case management by teachers should be considered. Activity Report · A developed national school malaria action plan should be consistent with the National The workshop was co-chaired by both the Ministries of Malaria Strategy (NMS), the Kenya Education Education and Health. After a brief self-introduction of Sector Support Programme (KESSP), the draft the participants (see attendance list), the background School Health Policy and the current skills- and the objectives of the workshop were introduced. based health education curriculum. Various stakeholders including the Ministries of Education and Health, the African Medical and Research Foundation (AMREF), the Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC), the Kenya NGO Alliance Against Malaria (KeNAAM), Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 45 Output of Group Work and Plenary Sessions BOX 2: In the afternoon session of day one, participants worked School Directed Antimalaria in four groups to review the malaria section of the draft Interventions - suggested revisions school health policy and the draft guidelines on malaria prevention and control in schools. The group work was presented and discussed during the plenary sessions. MALARIA The results of the discussion are presented in Boxes 1 a. Definition and 2 below. · A disease caused by a parasite called Plasmodium. b. Mode of Transmission · Transmitted through a bite from an infected female BOX 1: School Health Policy Anopheles mosquito. · Can also be transmitted through blood transfusion, which is infected with Malaria parasites if not screened before Document - suggested revisions transfusion or if an antimalarial is not given during transfusion. Malaria control c. Signs and Symptoms of Uncomplicated Malaria · Fever Malaria is the leading cause of morbidity and mortality in Kenya. It is · Headache also a significant health constraint on the education sector, causing · General body weakness school absenteeism and poor academic achievement. Schools and · Vomiting/nausea teachers have the potential to play an important role in malaria control · Joint pains through prevention and treatment. School-based strategies need to be · Loss of appetite consistent with the strategic priorities of the National Malaria Strategy. · Diarrhoea d. Management of Clinical Malaria 1) Clinical management · Teachers shall be guided to watch out for signs and · Skills-based health education to provide children with the symptoms of uncomplicated Malaria. knowledge and skills about the early recognition of the signs · Referral of children to health facility for management of and symptoms of malaria, and when to refer to the health Malaria. facility to access effective treatment. e. Prevention · Provision of teacher training to recognize signs and symptoms of malaria in ECD children and children with 1) Reduction of Contract between Human and Mosquito special needs, and appropriate referral to the health facility. · Use of ITNs, particularly the new LLINs. · Use of other personal protection measures, such as 2) Malaria in pregnancy mosquito repellents. · Skills-based health education to promote universal access to · Covering the body as much as possible, especially at night ITNs and IPT with SP for pregnant schoolgirls accessible to reduce mosquito bites. through health facilities. · Screen dormitories, classrooms and staff quarters with a mosquito mesh. 3) Insecticide-Treated Nets · Skills-based health education to encourage schoolchildren 2) Killing of Adult Mosquito · Spraying of dormitories, classrooms, staff quarters and other and their families to sleep under an ITN, particularly LLINs, buildings with IRS. and help establish use of a LLIN as normative behaviour amongst all members of the family. 3) Destruction of Breeding Sites/Source of Reduction · Establish and maintain storm water drains within the school 4) Epidemic preparedness and response and the immediate community. · Schools to support community-wide IRS. Schools can also · Reclaim swampy/soggy grounds within and around schools play an important role in the early detection of epidemics by (environmental guidelines on quarries to be followed). reporting unexpected increases in fever amongst pupils to · Larviciding breeding sites. the district authorities. 4) Health Education · Teachers are to provide simple messages to develop the necessary life skills related to malaria recognition, management and prevention. 46 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa The Proposed Plan of Action D. Strengthening of school health clubs in all schools to The second day was mostly devoted to charting the way include malaria prevention and control, including forward and developing the plan of action. assessment of current status of school health clubs. The purpose of this plan was to identify malaria-specific (3) Training of MoE/MoH staff, trainers of trainers activities which can be mainstreamed into ongoing and teachers: As part of the comprehensive school activities of the School Health and Nutrition Investment health package, to enhance training of Primary Programme of the KESSP. schoolteachers to include malaria-specific information. In each school, two teachers and the headteacher are to CURRENT ACTIVITIES be trained. In ECD and special needs schools, this training should cover the early recognition of malaria (1) Awareness and sensitization meetings and appropriate referral to the health facility. A. Regular coordination meetings between the Ministries of Education and Health, and other (4) Community-wide outreach through multi stakeholders i.e. Inter-agency Coordinating media channels: Produce media (radio and mobile Committee at the national level. film) messages focusing on malaria which can be included into current communication activities, such as B. Development of a malaria fact-sheet for use in: those focusing on HIV&AIDS. (i) divisional sensitization meeting; (ii) district sensitization meeting; and (5) Monitoring and evaluation: MoH to review the (iii) School Management Committee meetings at the current data collection and reporting instruments of the school level. Education Management Information System and school health indicators of the School Health Programme to (2) Skills-based health education ensure appropriate harmonization. This should also A. Review of existing malaria and school health IEC include rewarding best practices in school health material to identify gaps and provide recommendations. activities. B. Development of malaria-specific, age-appropriate IEC POTENTIAL ACTIVITIES WHICH REQUIRE materials to support the development of attitudes, FURTHER INVESTIGATION knowledge, and life skills among schoolchildren. In accordance with the NMS the following strategic topics (1) IPT in schools. should be covered: (2) Provision of first aid kits containing first line antimalarials and Rapid Diagnostic Tests, and · Clinical management: Provide children with the training of teachers to provide treatment. knowledge and skills about the early recognition of the signs and symptoms of malaria, and when to (3) Periodic mass screening of schoolchildren for refer to the health facility to access effective monitoring and evaluation of impact purposes. treatment. · Insecticide-treated nets (ITNs): Promotion of Concluding Remarks ITN use by schoolchildren and by their families, including priority groups such as under-fives and It was noted that making strong linkages between the pregnant women. Particular attention should be Ministries of Education and Health is not an easy task given to LLINs. and Kenya was commended for making good progress · Malaria in pregnancy: Promotion of universal towards this end. The two Ministries have two more or access to ITNs and IPT with SP for pregnant schoolgirls accessible through health facilities. less similar documents i.e. the National Health Sector Strategic Plan (MoH) and the Kenya Education Sector · Epidemic preparedness and response: Support Programme (MoE) and should therefore work Information on the need, purpose, method and closely with one another to avoid duplication of efforts. timing of community-wide IRS in epidemic-prone districts. C. Development of guidelines and manuals for use by teachers to help infuse malaria-specific life skills in the existing school curriculum at ECD, and primary and secondary levels. Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 47 Notes 48 Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa Notes Malaria Control in Schools: A toolkit on effective education sector responses to malaria in Africa 49