Exploring the Impact of Scaling up Mass Testing, Treatment and Tracking on Malaria Prevalence Among Children in the Pakro Sub District of Ghana
Phase: NA
Conditions: Malaria, Malaria, Asymptomatic Parasitaemia
Sponsor: Noguchi Memorial Institute for Medical Research

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Cover page 
 
 
Official Title: Exploring the impact of scaling up mass testing, treatment and tracking on 
malaria prevalence among children in the Pakro sub district of Ghana 
 
 
NCT: 
 
Date:  18/03/2018 
 
Document:  
Protocol 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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PROJECT SUMMARY  
Malaria poses a serious burden in sub-Sahara Africa. Efforts are ongoing to scale up 
interventions that work. These include the use of Long Lasting Insecticidal Nets (LLIN), 
Intermittent Preventive Treatment in children (IPTc), and test, treat and track (TTT). 
There is the need, however, for mass testing, treatment and tracking (MTTT) of the 
whole population to reduce the parasite load before implementing the aforementioned 
interventions. Though, Seasonal Malaria Chemoprophylaxis (SMC) is adopted for 
selected localities in Ghana, the impact of such interventions could be enhanced, if 
associated with MTTT in order to reduce the parasite load at baseline.  MTTT of 
children in Ghana has demonstrated a parasite load reduction from 25% to 1%. 
However, unanswered questions include - could this be scaled up?  What proportion 
of the community could be covered over a given time? What do the investigators need 
to accomplish large scale MTTT? In designing interventions that aim at reducing the 
burden of malaria in children under five, for example, MTTT has largely been left out. 
Adults who are not often targeted by such interventions remain reservoirs that fuel 
transmission. This study explores the scale-up of interventions that work using existing 
community volunteer teams to lower cost. These volunteers will play a surveillance 
role by conducting home-based management of malaria. To avoid challenges posed 
by stockouts, short message service (SMS) will be used to monitor the level of stocks 
for malaria medicine and Rapid Diagnostic Tests (RDTs). It is hypothesized that there 
are more asymptomatic malaria cases (those who carry the parasite but are not ill) 
than symptomatic cases reported by hospital records in the Pakro sub district and that, 
carrying out MTTT in combination with home-based management of malaria in specific 
communities could greatly reduce the burden. Through this study, the bottlenecks that 
hinder scaling-up of MTTT will be documented in order to facilitate the process. 
 
 
 
 
 
 
 
 
 
 
 
 
 

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GENERAL INFORMATION 
 
Protocol Title: Exploring the impact of scaling up mass testing, treatment and tracking 
on malaria prevalence among children in the Pakro sub district of Ghana 
 
PRIOR SCIENTIFIC REVIEW 
NMIMR STC Number: 4(2)2016-17 
NMIMR STC Approval Date: 4/10/2016 
 
Funding Source: WHO/TDR Postdoctoral programme (B40347) 
 
Principal Investigator:  
 
Ndong Ignatius Cheng (PhD, Pharmaceutics)  
Post-Doctoral Fellow  
Epidemiology Department,  
Noguchi Memorial Institute for Medical Research 
University of Ghana 
P. O. Box LG 581 Legon 
Tel: +233 561817573 
Email: NCheng@noguchi.ug.edu.gh 
 
  
Co-PIs:  
 
Collins Stephen Ahorlu, PhD 
Head of Department  
Department of Epidemiology  
Noguchi Memorial Institute for Medical Research 
T: +23321280162 
E-mail: cahorlu@noguchi.ug.edu.gh 
 
Prof. Kwado A. Koram, PhD 
Department of Epidemiology  
Noguchi Memorial Institute for Medical Research 
University of Ghana 
P. O. Box LG 581 Legon 
T:  +233 302 501180 
C: +233 240 313130  
Email: kkoram@noguchi.ug.edu.gh 
 
Prof. Alexander Nyarko PhD 
Dean School of Pharmacy  
University of Ghana 
P. O. Box LG 581 Legon 
Tel: +233203465071 
E-mail: ANyarko@noguchi.ug.edu.gh 
 
 
Mentors  
 

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Prof. Corinne Merle Simone Collette 
TDR  
Telephone: (+41) 22 791 2235 
E-mail:merlec@who.int  
 
Dr. Alfred Amambua Ngwa  
Medical Research Council  
The Gambia 
Tel: +2207817428 
E-mail: angwa@mrc.gm   
 
Stakeholders 
Ghana Health Service, Noguchi Memorial Institute for Medical Research (NMIMR), 
the local communities and WHO.  
 
Introduction/Rationale  
The World Health Organization (WHO) in 2010 reported that malaria was endemic in 
96 countries reflecting an improvement of the situation of 2005 where it was endemic 
in 106 countries (WHO, 2010).  Malaria morbidity and mortality remain a serious 
problem in sub Saharan Africa especially in areas with holo-endemic transmission 
(Appawu, Baffoe-Wilmot et al. 1994). Over the last decade, the number of recorded 
malaria cases has steadily dropped from 247 million cases with 881,000 deaths 
reported in 2006 to 198 million with 584,000 deaths in 2013 (WHO, 2009, 2010, 
2013). This has largely been due to the introduction of ACTs following the resistance 
witnessed against chloroquine as well as an increase in the number of control 
measures such as the use of insecticide treated nets, long lasting insecticidal nets 
(LLIN), vectors surveillance and intermittent preventive treatment in pregnancy 
(IPTp) and implementation of the WHO policy on test, treat and track (WHO, 2012). 
Despite the reported decrease, most of the endemic countries across sub Saharan 
Africa still bear the greatest burden of the disease where 90% of the deaths are 
reported with more than 75% of the mortalities in children under five (WHO, 2014).  
Ghana National Malaria Control Programme (GNMCP) reports reveal that in 2006 
malaria accounted for 37.5% of all out patient consultations, 36.0% of all hospital 
admissions, and about 33.4% of all mortality in children under age five years. 
Following the recommendation of the WHO, Ghana changed it malaria treatment 
guidelines adopting artesunate and amodiaquine as first line for the treatment of 
uncomplicated malaria to replace chloroquine (GNMCP, 2006). By 2012, hospital 
statistics across the country revealed that malaria was responsible for 38.93% of the 

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outpatient consultations and 38.80% of admissions. Of those admitted for malaria, 
63% were children under 5 years of age while pregnant women constituted 16.8%. 
Furthermore, According to the Ghana Health Service (GHS) report of 2012, malaria 
accounted for 22.4% deaths in children less than five years of age and 3.4% deaths 
among pregnant women (GHS, 2012). Over the last decade, studies in Ghana have 
demonstrated that artesunate and amodiaquine combinations are not only 
efficacious in clearing the malaria parasites from patients (Koram et al. 2008) but if 
used for intermittent preventive treatment programmes for children under five could 
effectively clear more than 90% of the parasite in this age group (Ahorlu et al. 2009).  
Different studies have demonstrated very high level of asymptomatic malaria 
parasitaemia in both less than 5 years old and school age children. In 2009, Ahorlu 
et al, reported a parasite prevalence of 25% in less than five year old children in the 
Shime sub district in the coast of Ghana. In the same light, (Otupiri et al. 2012) 
reported a malaria parasitaemia prevalence of 58.6% among school children in the 
Ejusu Juaben District, while (Sarpong et al. 2015) reported a 41.5% prevalence of 
malaria parasitaemia in Ghanaian school children in the Ashainti and Upper West 
regions of the country. A related study in the Dodowa area demonstrated that 
children with high levels of asymptomatic parasitaemia have a higher risk of coming 
down with clinical malaria (Ofosu-Okyere et al. 2001).  
The link between one parasite carrier or infected individual and the next relies on the 
mosquito picking up the parasite during a blood meal. This means that even if all 
patients with malaria are treated of the disease, those individuals who carry the 
parasite and are not ill could redistribute it to the healthy population with the help of 
the mosquito and therefore, the cycle simply continues. The high incidence of 
asymptomatic parasitaemia serves as a reservoir that fuels the malaria transmission 
cycle (Bousema et al. 2014 et al. 2016). If the parasite is cleared from the blood of 
asymptomatic individuals as well as the sick patients with the very efficacious 
Artemisinin-based Combination Therapy (ACT), then, even the most effective 
mosquito vector would have nothing to transmit following a blood meal (Ahorlu et al. 
2011).  
Continuous exposure to the malaria parasite has led to the development of immunity, 
especially in adults in endemic areas. This is often a slow process as it depends on 
repeated exposure to the parasites (Greenwood, 1987, Njama-meya et al., 2004). 

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This explains why children carry the greatest burden of the disease. As they grow 
beyond age 5 years, the prevalence of malaria or parasitaemia in this group begins 
to decrease following the development of immunity to the parasite (Bull et al. 1998). 
Age, therefore, has a great role to play when looking at the dynamics of the malaria 
burden. A study of trends in malaria admission in a Health Centre in Cameroon has 
demonstrated that the variation in the prevalence of malaria effectively reflected a 
variation in the prevalence in children age one to less than 15 years (Ndong et al. 
2014). In endemic areas, children have been reported to harbour relatively high 
levels of the parasite without coming down with the disease (Snounou et al. 1997), 
and the population is continuously exposed to the infected mosquitoes. That is, the 
already parasitised individuals can be re-infected either with the same parasite, thus, 
increasing the parasite load or other parasite species leading to a co-infection in 
areas with more than one species of Plasmodium.  On the other hand, the uninfected 
mosquito is initially harmless even if it bites. However, it becomes infective when 
infected by a parasitised individual who could either be febrile or asymptomatic. 
Therefore, while enormous effort is being made to prevent man-vector contact 
through the use of treated nets, the benefits from using these nets could be amplified 
if such programmes integrate mass parasite clearance as part of their agenda. That 
is mass testing, treatment and tracking should precedes the mass distribution of 
LLIN in a given area or intermittent preventive treatment in children.  
There has been concerted effort in the past decade to evaluate the possible effects 
of massive parasite clearance using intermittent preventive treatment in less than 
five year old children in different part of Africa with interesting results. Most studies 
however, focused on the clinical incidence of the disease as outcome measure 
which has been observed to reduce with a range of between 20-80% depending on a 
number of factors (Dicko et al. 2008, Kweku et al. 2009). In a longitudinal study in a 
Coastal village in Ghana, Ahorlu et al, demonstrated that associating IPTc with home 
based management of malaria by community workers could clear more than 90% of 
the parasite pool in the community. This intervention reduced malaria parasitaemia 
prevalence from 25% at baseline to 1% at evaluation using artesunate and 
amodiaquine. This low level of parasitaemia in the study population was found to 
persisted over a period of two years (Ahorlu et al. 2011). Though, this intervention 
had targeted only under 5 years children, it revealed the potential role intermittent 
preventive treatment of the population could play in reducing malaria prevalence and 

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consequently paving the way for malaria elimination. Given that old members of the 
household are likely to have some immunity to the malaria parasite, they however, 
represent the reservoir that refuels the parasite pool whenever it is reduced by IPTc. 
Therefore, for sustainability of such implementation intervention, intermittent 
preventive treatment would be of greater benefit if all the members of each given 
household are targeted for mass testing, treatment and tracking at baseline and 
consequent prompt home-based treatment for suspected cases. Bearing in mind that 
huge resources are required for IPT of whole communities, it has been suggested 
that mass screening of whole communities be carried out once a year while IPTc be 
conducted regularly in combination with the home based management (Ahorlu et al. 
2011). This could further enhance the efforts.  
Implementation of rapid scale–up preventive interventions in the past decade has led 
to a reasonable decrease in the burden of the malaria (WHO 2011) especially given 
the introduction of the WHO policy of test, treat and track (T3) (WHO 2012). The 
challenges involved with translating research scenarios into implementation are 
enormous. It is important to understand the bottlenecks that hinder this process in 
order to undertake mass testing, treatment and tracking in a large scale using 
existing health systems, especially in an era when global funding for health services 
is slowing down (Rao et al. 2013).  
Any effective control strategy that interrupts the link between man, the parasite and 
the vector could seriously reduce the transmission of malaria. In this light, 
interventions focused on clearing of the parasites in asymptomatic individuals in 
combination with intensive use of other control measures could pave the way for pre-
elimination of the parasite in endemic communities (Bousema et al. 2014). This 
study aims at reducing the asymptomatic parasitaemia in the Pakro sub district of the 
Eastern Region of Ghana by conducting MTTT for malaria parasitaemia among 
household members of age 6 months and older and carrying out targeted treatment 
of all cases with confirmed asymptomatic parasitaemia or clinical malaria. These 
interventions intend to follow up enrolled participants over a period of two years. 
Hospital records will also be studied to document trends in malaria admissions and 
occurrence of other diseases in the area before and after the interventions.  
 
Rationale  

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Malaria continues to poses a serious burden to the local populations in sub-Sahara 
Africa. Several efforts have been made to scale up interventions that work such as 
preventing man-vector contact, intermittent preventive therapy, seasonal malaria 
chemoprophylaxis as well as TTT for febrile patients (WHO, 2012). However, much 
still has to be done to target the mass testing, treatment and tracking of whole 
populations in order to reduce the parasite load before implementing the above 
mentioned interventions. Though SMC is adopted for selected localities in Ghana, 
MTTT could be used to drastically bring down the parasite load in a given population 
before the implementation of interventions such as SMC.  Elsewhere, it has been 
demonstrated that incorporating the antimalarials in vaccination programmes could 
delay the first malaria episode in children under five (Dicko et al., 2008). 
Furthermore, MTTT of children in a community in Ghana has been reported to 
reduce the parasite load in a given community from 25% to 1% (Ahorlu et al., 2011). 
The questions that remain are - could this be scaled up?  What proportion of the 
community could be covered over a given time? What will it take to accomplish 
MTTT in large scale? In designing interventions that aim at reducing the burden of 
malaria in children under five, for example, MTTT could be used to clear parasites 
from the general population before the interventions are implemented. This is 
because the adults who are not often included in the interventions that target 
children under 5 years old tend to act as reservoirs that fuel the transmission. To 
solve the problem of personnel who are limited at the level of the health service and 
coverage, this study will be making use of the existing network of community 
nurses/volunteer teams that are used during vaccination programmes. These 
volunteers, who recite in the communities, will carry out the interventions in the given 
communities and conduct the home-based management of malaria between 
interventions thereby increasing surveillance and reducing cost. Furthermore, to 
solve the problem of stock-outs and quality of the RDTs and antimalarials, the 
investigators will make use of SMS through mobile phones and a team will conduct 
monthly monitoring and evaluation of the field activities of the volunteers as well as 
refill the medicine and RDTs. The volunteers will be trained based on the 2014 
guidelines for managing uncomplicated malaria.  
The investigators hypothesize that in the Pakro sub district, there are more 
asymptomatic malaria cases than the symptomatic cases reported by hospital 
records and that if the investigators carry out MTTT in combination with home-based 

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management of malaria in specific communities over two years, a large proportion of 
the parasite reservoir will be cleared and consequently open up possibilities for pre-
elimination of malaria in the area. It is also intended that the bottlenecks involved in 
scaling up mass testing, treatment and tracking will be documented in order to 
facilitate the process. 
 
Main objective 
The main objective of this study is to explore the impact of scaling up mass testing, 
treatment and tracking on malaria prevalence among children under fifteen years of 
age in the Pakro sub district of Ghana.  
 
Specific Objectives  
1. To evaluate the effect of scaling up targeted MTTT/home-based treatment on 
malaria parasitaemia and hospital consultations and admissions. 
2. To determine the prevalence of asymptomatic parasitaemia among afebrile 
participants. 
3. To reduce the burden of malaria in the participating communities.  
4. To document challenges which hinder the scale up of mass testing, treatment 
and tracking of malaria in Ghana. 
5. To conduct a cost benefit analysis of the intervention in the area.  
 
Study Design:  
This is an Implementation Research (IR) with a longitudinal cohort design to be 
undertaken within a two year frame work. The interventions are designed to compare 
the baseline to evaluation findings following the modified protocol of (Ahorlu et al., 
2011). There are two components to this implementation study a). The 
longitudinal (cohort) study: This is basically the prevalence surveys to be 
conducted with the selected cohort of children 6 months to 15 years – at 
baseline and before each of the subsequent MTTT rounds. b). The Survey 
involves using structured questionnaire to interview caretakers of children 
under five to solicit their views on the implementation process perceived 
benefits and challenges etc. Though the target group is children from 6 months to 
15 years of age, all parasitised adults will be cleared of the parasite during the 
interventions as well to reduce the parasite reservoirs. Prevalence of malaria 

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trends in cohort group over the study period will reveal the effect of MTTT 
scale-up on the children 6month to 15 years. Between interventions, the teams 
will conduct homes-based management of malaria for all febrile cases confirmed to 
be positive for malaria parasites. The challenges faced by the implementation team 
will be documented at every stage and discussed with all the stakeholders at every 
stage of the implementation. 
 
Methodology  
 
Study Area 
Pakro is one of five sub-districts in the Akwapim south district health directorate 
(DHD) in the Eastern region of Ghana (DHD, 2014). The Akwapim south district lies 
within the semi-equatorial climatic region, and experiences two rainfall seasons in a 
year, with an average rainfall of 125cm to 200cm. The first rainy season begins from 
May to June with the heaviest rainfall in June, whilst the second rainy season begins 
from September to October. According to the Ghana Statistical Service (GSS),  the 
average household size in the Akwapim South district is estimated to be 4.0 whilst 
the average number of households per house or compound is estimated to be 1.6 
(GSS, 2010). The Pakro sub-district has an estimated population of 7,889, and is 
bounded to the east by Akwapim North district; to the north by Ayensuano district; 
and to the west by Nsawam Adoagyiri Municipality. The sub-district is made up of 22 
communities, and has 3 health care facilities (1 Health Centre and 2 Community-
Based Health Planning Service (CHPS) compounds) (DHD, 2014).Due to limited 
resources, only seven communities will be selected for this study. This include 
Abeasi Newsite, Fante Town, Zongo (Adjenase/Kweitey), Piem/odumsisi, Adesa 
Latebibio, Sacchi/Tabankro and Odum Tokuro. These are communities with a 
relatively high population density. The Pakro Health Centre is one of thirty sentinel 
sites monitoring malaria prevalence in the country coordinated by the Noguchi 
Memorial Institute for Medical Research (NMIMR). Malaria parasite positivity rate 
was estimated to be 45.7% in 2014 (DHD, 2014). In the same year anaemia among 
pregnant women at 36 weeks of gestation was 21% (DHD, 2014).  
 
Study participants  

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Community entry activities to sensitise the chiefs and the general population will be 
conducted at the beginning of the study through meetings and durbars (Ansah et al., 
2015; Ahorlu, et al., 2009). Once the community leaders and the population have 
accepted the project, the household will be numbered and participants per 
household will be registered during a household census. All households will be given 
a unique identification code. Each individual within the household will be assigned a 
code that links them to a particular household and community. After obtaining 
consent from the household heads, the children will be enrolled but individual assent 
and consent will be obtained from the other adolescents and adults in the household. 
A cohort of 460 children age 6 months to 15 years will be selected and enrolled 
into the longitudinal study which will consist of prevalence surveys 
undertaken before each MTTT. Caregivers of the children in the cohort will be 
enrolled for the community surveys using questionnaires. In this 
implementation research the entire population of the seven selected 
communities will be tested, treated and tracked. This is intended to clear the 
parasite pool in the community.  
 
Intermittent preventive treatment for the household members 
The research team together with Community assistants/volunteers will conduct 
house-to-house testing (using RDTs) of all children (from 6 months old) and adults 
residing in 7 selected communities for the presence of malaria parasites. For this 
study, the investigators will use the Ag P.f RDT which detects histidinie-rich 
proteins II antigens (HRP-2 Ag) specific to P.falciparum in human blood. The 
RDTs will be supplied by the Ghana Health service through the National 
malaria control programme which uses the services of WHO-FIND Lot Testing 
Programme for quality assurance. Thus, the investigators are using the same 
RDT that has been procured by the NMCP and are being used routinely in 
Ghana. To enable follow up studies in a case where treatment failure is reported, 
200ul (two drops) of blood will be collected on filter paper. This will be used to 
determine immunological parameters such as antibody levels to specific antigens 
using Polymerase Chain Reaction (PCR) and Enzyme Linked Immunosorbent Assay 
(ELISA). RDT confirmed cases who are treated but presents persistent malaria 
related symptoms  such as fever  on day 7 will be tested using microscopy and 
to determine clinical failure. This study is not designed to test for parasite 

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resistance to drug (drug efficacy) and the Project clinicians will advise on the 
next line of action. This could be taken up by a masters’ student. However, the 
student will need to submit a different protocol to the ERC for approval).  All 
participants confirmed (using RDTs) to be carrying the malaria parasite will be 
treated using ACTs following the Ghana National Malaria Treatment Guidelines and 
followed up on days 1, 2, 3 during treatment as DOTs (Directly observed 
therapy) and on day 7 post treatment. The research team together with 
Community volunteers will be provided the treatment guidelines which specify 
the dosage for each treatment regimen. Participants who receive the treatment 
will be observed for five minutes to ensure that they retain the drug. Those who 
vomit within this period will have the treatment repeated.  
 
Follow-Up 
All treated cases will be followed up on days 1, 2, 3 during treatment and day 7 
post-treatment to ensure that the participants take the drugs on time as well as 
document and report all adverse effects. 
 
Questionnaire/Focus group Discussion  
The questionnaire will include questions about malaria treatment, prevention and 
control measures practiced by the household members. Occupants of the household 
will provide a blood sample for testing. Focus group discussions will be 
organized with community members and health care workers to increase the 
scope of information obtained.  
 
Timely treatment of suspected febrile malaria case in the community 
In other to render operational the home-based management component of the 
project, two volunteers will be selected from each community and trained on home-
based management of malaria and be provided with the protocol, RDTs and ACTs. 
The interventions will be carried out quarterly (see the timetable). Between one 
MTTT intervention and the next trained community members will provide prompt 
home-based treatment for children and adults reporting signs and symptoms of 
malaria and confirmed to be carrying the parasite using RDTs. This will be done 
using national malaria management protocol. There will be monthly visits by the 
research team to supervise the community volunteers involved in home-based 

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management to ensure that the protocol is being respected as well as replenish their 
stocks. There is a need to visit the health facilities that service the community to 
enable tracking and linking of medical records with study participants (a master 
student is required for this component). The investigators hypothesize that a 
reduction in parasite load in the community will consequently lead to a reduction in 
the number of hospital malaria related consultations and admissions paving the way 
for pre-elimination. This will be realised by comparing baseline hospital malaria 
admission data to evaluation data. MTTT has already been adopted by the NMCP as 
one of the control and elimination activities and the investigators are anticipating its 
being scaled-up in the country, and therefore documenting its implementation challenges will 
inform the decision in the future. 
 
Sample size 
This is an implementation study aimed at enrolling an entire population estimated at 
4500 participants from the 7 selected communities in Pakro sub district. This 
population was obtained following data from a head count in preparation for the 
mass distribution of LLIN in 2016 - Abase newsite = 800, Fante town = 1450, 
Adjenase/Kwettey = 1102, Piem/Odumsisi = 323, Adesa/Nsuablaso = 480, 
Sacchi/Tabnkro = 201, Odumtokro = 129 (Pakro Health Centre records). However, 
since the target effect of this intervention is focused at the children age 6 months to 
15 years, a community survey with a sample of 368 children will be needed to 
determine the malaria prevalence projected at 50% in the study population. This has 
been determined using the formula  of  Yamane where n = N/[1+N(е)2] (Israel 1992)  
considering a 95% confident level (CI) and ±5% precision.  Assuming a loss to follow 
up of 10% and a non-response rate of 10%, the sample size is readjusted to 460 
children calculated from (38/1-0.2) for the community survey. At evaluation the 
available sample size will be determined. This is the group for which questionnaires 
will be administered. Following a census of the households, children under 6 months 
to 15 years old will be randomly selected for the longitudinal cohort study, they 
will then be divided into the various age groups 6 months to 11 months, 1-4 years, 5 
-10 years and 11-15 years. For each age group the investigators will randomly select 
116 children. 
 
Inclusion criteria   

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To be included in the longitudinal cohort study, participant must be between the age 
range six months to 15 years and be resident in the study area for the period of the 
study. Willingness to participate will be proven by a completed and signed consent 
form from the parent or guardian of each child. All other community members will be 
engaged in the survey studies. 
 
Exclusion criteria 
If an individual intents to stay less than one year in the study site or would be absent 
at some time because he/she is schooling in a boarding school or has a life 
threatening illness (excluding malaria). However, all individuals including those with 
clinical malaria signs who are present during surveys will be tested and if confirmed 
to carry the parasite will be treated.    
 
Data collection  
Following consent, blood will be drawn from a finger prick. All participants will be 
tested for the presence of malaria parasites using RDTs. Additionally, blood will be 
collected on filter paper to enable molecular characterization in case treatment 
failure is observed in a given patients as explained above. All samples will be stored 
at NMIMR. To test for anaemia (for children in the cohort study only), a portable 
automated Hemocue photometer will be used to determine the concentration of 
Haemoglobin. Anaemia in this study is defined as Hb levels less than 10g/dl. 
Children with severe anaemia (Hb less than 7g/dl) will be referred to the Pakro 
Health Centre for follow up. At evaluation, family members will be asked 
questions on how much they used to spend on malaria before the intervention 
and how much they have spent after. Malaria case management records before 
and after the intervention will be consulted, firstly to determine the change in 
prevalence and also for cost benefit analysis purposes.  
 
Data Management and Analysis  
Data Management will be conducted with the support of the Data management unit 
in the Department of Epidemiology of NMIMR. A database will be created to manage 
the data. Data will be entered into Epi-info and analysed using SPSS. The unit of 
enrolment will be the household. Malaria prevalence will be reported as, proportion 
of subjects identified during the study period with RDT confirmed clinical malaria with 

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temperature ≥37.5 or asymptomatic parasitaemia and stratified by subject 
characteristics, including age, sex and community. A Chi square statistic will be used 
to compare prevalence across age and gender categories as well as communities. 
To determine whether interventions had an effect on the prevalence of malaria 
in the area, the baseline prevalence data will be compared with the evaluation 
data. Also a cost benefit analysis will be conducted by comparing what the 
NMCP put in in previous years to treat malaria to what it would spend if MTTT 
is implemented.  
 
Problems Anticipated 
It is anticipated that ACTs and RDTs supplies could delay. In order to avoid this, the 
investigators have approached the national malaria control programme to 
arrange for drugs and RDTs supply through the Eastern Regional Store. The 
investigators anticipate the number allocated to houses in the communities 
could be wiped and so the investigators have each house data linked to the 
name of the house. This could enable us to trace the participants easily. In the 
field  the investigators will use forms that already carry the names of the 
families following the census. Names of new people could be added.  
 
Project Management 
The PI will carry out day to day implementation and supervise of all aspect of the 
project. Co-PIs are part of the implementation team and will participate in the 
decision making at all stages of the project. The Research assistant will help in 
facilitating project logistics. The Regional/District Health Directorates through the 
health facility in Pakro will facilitate the work. The volunteers are community 
members that assist in data collection while the driver facilitates movements. 
 
Quality Assurance 
In order to ensure the quality of data collected, 20 volunteers will be trained and 14 
will be selected for the project. The questionnaires will be pretested and corrections 
effected. All data collected will be cross checked by two persons in the fields. To 
avoid loss of data, all data from the field will be recorded in the data transfer sheet 
before being transferred to the data management unit. All ACTs and RDTs will be 

16 
 
procured from the National Malaria Programme through the Eastern Region medical 
store. The expiry dates for all procurements made will be verified.  
 
Ethical Consideration  
 
The ethical clearance for this study will be sought from the GHS-ERC 
 
Consent Procedure 
The investigators will obtain consent at different levels. Administrative authorization 
will be obtained from the Ghana Health Service. There will be community consent 
given by the chiefs, households consent given by the head or parents/caretakers for 
children below 18 years, individual assent for 12-17 years old and consent for adults 
in each household. People from 18 years old are considered as Adults. 
 
Privacy and confidentiality  
All information/samples obtained from participants and their results will be kept 
confidential and not be released to a third party.  
 
Data storage and Usage 
This information will be stored in a secure location at the Epidemiology 
Department of NMIMR. Some staff of Epidemiology Department of NMIMR may 
access the data for research purposes only, such as malaria prevalence 
studies in asymptomatic individuals. Findings will be published with no 
reference to any personal identifiers. The data collected will be stored for a 
period of five years at NMIMR. 
 
Data ownership 
Data resulting from this study is own by the NMIMR. 
 
Risk 
There is no health threatening risk. Some participants may vomit within five minutes 
after taking the ACTs. It is assumed that if a patient vomits within five minutes he/she 
has not absorbed an acceptable quantity of the medicine. In this case the treatment 
will be repeated (Ahorlu et al., 2009). Some other patients may show adverse 

17 
 
reactions after taking the drugs such as stomach upset, dizziness, nausea,  body 
weakness, etc (Sinclair et al., 2009). In other to cross check for some of these 
adverse events, the team will monitor volunteers for four days following treatment.  
 
Conflict of Interest 
The PI and co-PIs declare no conflict of interest in the execution of this 
project. 
 
Benefits 
All confirmed malaria parasitaemia cases will be treated for free. Continuous 
monitoring and treatment of confirmed cases will improve the health of residents. 
The study will reduce household spending on malaria thereby free some funds to be 
spent on other household items. This project could reduce the malaria related 
burden in the implementing communities. 
 
 
Expected Outcome/Results 
1. The effect of scaling up targeted MTTT/home-based management on hospital 
admissions will be understood.  
2. The prevalence of asymptomatic malaria parasitaemia among afebrile 
children aged 6 months to 15 years and adults in the Pakro sub district will be 
known.  
3. Reduced burden of malaria in the participating communities  
4. Document challenges that hinder the scale up of mass testing, treatment and 
tracking of malaria in Ghana. 
5. The cost benefit analysis of the scaling up MTTT intervention in the area will 
be known.  
 
Dissemination 
The findings of this study will be discussed at every stage with stakeholders and 
published. 
 
Work Plan 
 
Outcome  
Measure  
Time frame  Mile stone  
Proposal 
development 
Draft proposal is available  
Aug –Oct 
2016 
Submitted to the 
STC/IRB 

18 
 
Ethical Clearance  
Ethical clearance is obtained 
Nov - Jan 
2016 
clearance is 
available 
Administrative/ 
Ethical clearance 
from Ghana Health 
Service 
Administrative and GHS-ERC 
clearance are obtained 
Feb – April 
2016 
Clearance is 
available 
Communities/durbar Meeting/durbars held 
Nov 2016 
Project is accepted 
by the community 
Mapping of 
households /census 
of participants 
All households are numbered and 
individual identified 
Nov  2016 
Each households 
has a number 
Planning for data 
collection 
Consumables are prepared, RDTs 
are bought 
Dec - Jan 
2016 
All necessary 
equipment and 
consumable are 
available in the field  
Primary  
The prevalence of asymptomatic 
malaria parasitaemia among 
afebrile children aged 6 months to 
15 years and adults will be known 
in the Pakro sub district. 
Two years  
 
1st survey 
Apr - Jul 
2017 
 
2nd survey 
Aug - Oct 
2017  
 
 
3rd survey 
Nov - Jan 
2017 
 
4th survey 
Feb - May 
2018 
 
5th survey 
Jun - Sep 
2018 
 
6th survey 
Nov 2018 - 
Feb 2019 
Reports, 
Publications, 
Presentations at 
conferences and 
workshop 
demonstrating the 
effect of the 
intervention on 
malaria prevalence 
in Pakro sub district 
in the Eastern 
Region of Ghana 
Secondary  
Reduce the burden of malaria in 
the participating communities. 
Challenges that hinder the scale 
up of mass testing, treatment and 
tracking of malaria in Ghana are 
documented.  
The cost benefit analysis of the 
scaling up MTTT intervention in 
the communities will be known. 
Options for policy are proposed. 
Evaluation 
What is the effect of the 
intervention? What is the 
prevalence? What are the lessons 
learned for scaling up. 
Jan - July 
2019 
Report 
publication 
 
 
References 
 

19 
 
AHORLU, C. K., KORAM, K. A., SEAKE-KWAHORLU, A., ATSU & WEISS, M. G. 
2011. Two-year evaluation of Intermittent Preventive Treatment for Children 
(IPTc) combined with timely home treatment for malaria control in Ghana. 
Malaria Journal, 10, 1. 
AHORLU, C. K., KORAM, K. A., SEAKEY, A. K. & WEISS, M. G. 2009. 
Effectiveness of combined intermittent preventive treatment for children and 
timely home treatment for malaria control. Malaria Journal, 8, 1. 
APPAWU, M., BAFFOE-WILMOT, A., AFARI, E., NKRUMAH, F. & PETRARCA, V. 
1994. Species composition and inversion polymorphism of the  
.Anopheles gambiae complex in some sites of Ghana, West Africa. Acta tropica, 56, 
15-23. 
BOUSEMA, T., OKELL, L., FELGER, I. & DRAKELEY, C. 2014. Asymptomatic 
malaria infections: detectability, transmissibility and public health relevance. 
Nature Reviews Microbiology, 12, 833-840. 
BULL, P. C., LOWE, B. S., KORTOK, M., MOLYNEUX, C. S., NEWBOLD, C. I. & 
MARSH, K. 1998. Parasite antigens on the infected red cell surface are 
targets for naturally acquired immunity to malaria. Nature Medicine, 4, 358. 
DISTRICT HEALTH DIRECTORATE, 2014. District Annual Report 2014, Akwapim 
South, Aburi, Ghana.  
DISTRICT HEALTH DIRECTORATE, 2015. District Annual Report 2015, Akwapim 
South, Aburi, Ghana 
DICKO, A., SAGARA, I., SISSOKO, M. S., GUINDO, O., DIALLO, A. I., KONE, M., 
TOURE, O. B., SACKO, M. & DOUMBO, O. K. 2008. Impact of intermittent 
preventive treatment with sulphadoxine-pyrimethamine targeting the 
transmission season on the incidence of clinical malaria in children in Mali. 
Malaria Journal, 7, 1. 
GNMCP 2006. Ghana National Malaria Control Programme: Ghana Health Service 
Report 2006 Accra. 
GHANA STATISITCAL SERVICE, 2010. Population and Housing Sensus. District 
Analytic Report: Akwapim South District. 
ISRAEL, G. D. 1992. Determining sample size, University of Florida Cooperative 
Extension Service, Institute of Food and Agriculture Sciences, EDIS. 

20 
 
KORAM, K., QUAYE, L. & ABUAKU, B. 2008. Efficacy of amodiaquine/artesunate 
combination therapy for uncomplicated malaria in children under five years in 
Ghana. Ghana Medical  Journal, 42, 55-60. 
KWEKU, M., WEBSTER, J., ADJUIK, M., ABUDEY, S., GREENWOOD, B. & 
CHANDRAMOHAN, D. 2009. Options for the delivery of intermittent 
preventive treatment for malaria to children: a community randomised trial. 
PLoS One, 4, e7256. 
NDONG, I. C., VAN REENEN, M., BOAKYE, D. A., MBACHAM, W. F. & GROBLER, 
A. F. 2014. Trends in malaria admissions at the Mbakong Health Centre of the 
North West Region of Cameroon: a retrospective study. Malaria Journal, 13, 
1-12. 
NEWELL, K., KIGGUNDU, V., OUMA, J., BAGHENDAGE, E., KIWANUKA, N., 
GRAY, R., SERWADDA, D., HOBBS, C. V., HEALY, S. A. & QUINN, T. C. 
2016. Longitudinal household surveillance for malaria in Rakai, Uganda. 
Malaria Journal, 15, 1. 
OFOSU-OKYERE, A., MACKINNON, M., SOWA, M., KORAM, K., NKRUMAH, F., 
OSEI, Y., HILL, W., WILSON, M. & ARNOT, D. 2001. Novel Plasmodium 
falciparum clones and rising clone multiplicities are associated with the 
increase in malaria morbidity in Ghanaian children during the transition into 
the high transmission season. Parasitology, 123, 113-123. 
OTUPIRI, E., YAR, D. & HINDIN, J. 2012. Prevalence of Parasitaemia, Anaemia and 
treatment outcomes of Malaria among School Children in a Rural Community 
in Ghana. Journal of Science and Technology (Ghana), 32, 1-10. 
RAO, V. B., SCHELLENBERG, D. & GHANI, A. C. 2013. Overcoming health 
systems barriers to successful malaria treatment. Trends in Parasitology, 29, 
164-180. 
SARPONG, N., OWUSU-DABO, E., KREUELS, B., FOBIL, J. N., SEGBAYA, S., 
AMOYAW, F., HAHN, A., KRUPPA, T. & MAY, J. 2015. Prevalence of malaria 
parasitaemia in school children from two districts of Ghana earmarked for 
indoor residual spraying: a cross-sectional study. Malaria Journal, 14, 1-7. 
SINCLAIR D, ZANI B, DONEGAN S, OLLIARO P, GARNER P. 2009. Artemisinin-
based combination therapy for treating uncomplicated malaria. Cochrane 
Database of Systematic Reviews, Issue 3. Art. No.: CD007483. DOI: 
10.1002/14651858.CD007483.pub2. 

21 
 
SNOUNOU, F., ROOTH, I. & BJORKMAN, A. 1997. Daily dynamics of Plasmodium 
falciparum subpopulations in asymptomatic children in a holoendemic area. 
American Journal Tropical Medicine and Hygine  56, 538-547. 
WORLD HEALTH ORGANISATION Roll Back Malaria Report. Geneva: WHO; 2003. 
http://www.rollbackmalaria.org/microsites/wmd2011/amr_toc.html. Accessed 
15 November. 2016  
WORLD HEALTH ORGANISATION. World Malaria Report 2009. Geneva: WHO; 
2009 http://www.who.int/malaria/world_malaria_report_2014/en. Accessed 3 
December. 2016  
WORLD HEALTH ORGANISATION. World Malaria Report 2010. Geneva: WHO; 
2010. http://www.who.int/malaria/world_malaria_report_2010/en. Accessed 1 
December 2016  
WORLD HEALTH ORGANISATION. World Malaria Report 2011. Geneva: WHO; 
2013 http://www.who.int/malaria/publications/world_malaria_report_2013/en. 
Accessed 2 December 2016 
WORLD HEALTH ORGANISATION. World Malaria Report 2014. Geneva: WHO; 
2014 http://www.who.int/malaria/publications/world_malaria_report_2014/en. 
Accessed 1 December, 2016 
WORLD HEALTH ORGANISATION (2012). "T3: Test. Treat. Track. Scaling up 
diagnostic testing, treatment and surveillance for malaria." Geneva, 
Switzerland: WHO Press. Retrieved July 9: 2013. 
 
 
 

22 
 
 
Budget & Budget Justification 
 
Budget  
 Item 
 specification 
 Cost ($) 
RDTs 
Ag P.f/Pan test is a rapid, qualitative and 
differential test for the detection of histidine-rich 
protein II (HRP-II) antigen of Plasmodium 
falciparum  in human whole blood. 
19,958.4 
Treatment 
Artemether lumefantrin (AL) for both adults and 
children. The number of treated cases will be 
decreasing over time. 
6,690 
Hemocue 
photometer 
Hb levels will be assessed to determined anaemic 
status. 
2,582 
Consumables/ 
materials 
Gloves, tissue, zip-lock bags, safety boxes and 
silica gel, filter paper and PCT reagents 
2,024  
Incentives for 
Under five children 
Biscuits 
2,025 
Data analysis 
Statistician will enter the data and conduct analysis 3,000 
Community entry 
Meetings and durbars with chiefs  
70.0 
Longitudinal 
Cohort study 
Questionnaires will be administer to parents of 
enrolled children or guardians  
3,895.5 
Training 
Aquent the volunteers with the intervention 
instruments and pretest. 
832.32 
Study of hospital 
admission records 
To study admission trends 
2,500 
Communication 
Communication credit enable the team liaise with 
the volunteers on home-based management. 
1,149.12 
Bags for the 
volunteers 
These are require for transport of materials 
510 
Home-based 
management of 
malaria  
 14 community volunteer (2 from each community) 
conduct home-based management of malaria 
following the protocol. 
2,112.6 
Personnel 
Census and mapping the study site, 6 surveys 
visits and the monitoring visits. The team includes 
1 driver, 1 Research Assistant, 14 community 
volunteers and one PI.  
15,232.09 
Rechargeable 
lamp 
In case there is no light (2) 
123.48 
Transport 
Car hiring, fuel for censor, surveys and monitoring 
10,567 
Conference / 
workshops and 
training 
  
 10,000 
Publication 
 
6,000 
Total 
93,508.78 + 5% contingency 
98,184.209 
 

23 
 
 
Explanation of Budget 
 
Intervention team members  
The project team will be composed of one Principal Investigator (PI), 1 research 
assistant, and 14 community workers and a driver. We will require two cars for each 
survey which will last 16 days. Surveys will take place quarterly, making a total of 6 
interventions over two years.  
 
RDTs 
Survey 
A pack contains 40 RDTs. Given that the target population of the targeted 
communities is 4,500 people, it is important to buy 5000 RDTs for each intervention 
(i.e. 125 packs). This is because some of the RDTs could give inconclusive results 
which will require that the process be repeated. Each RDT pack of 40 cost $25.15. 
Each RDT cost $0.63. The total cost for RDTs for the 6 surveys is given by 
($0.63*5000*6) of $18,900. Pakro Health Centre is a sentinel site for monitoring 
malaria prevention which is being let by the Epidemiology Department of Noguchi. In 
this light, the RDTs and Antimalarials will be obtained from the National Malaria 
Control Programme, so the estimated cost which was based on RDT and drugs has 
been dropped. 
 
Home-base testing 
We estimate that the volunteers will test 10 suspected case of malaria each month. 
Given that there are 7 communities, we have (7*10*24) = 1680 RDTs. Total cost for 
home based testing is given by $0.63*1680 = $1,058.4. 
Total cost of RDTs 1,058.4 + 18,900 = 19,958.4 
 
Anaemia 
Anaemia is estimated to be 27% in under five children. It is estimated that 30% 
(1350) of the population of Pakro is made up of children under five years, giving 
1350*0.27 = 365 anaemic cases. Assuming a 5% reduction after the first 
intervention, in the second intervention we will target 22% aiming at reducing it to 17 
% while in the third intervention we aim to reduce it to 12%. For cost purposes we 

24 
 
will maintain it at 12% after the third intervention. Hemocue photometer = $1000, 
total number of micro cuvettes = 365 + 297 + 4(230) = 1,582. One cuvette cost $1, 
giving ($1*1,582) = $1,582.  
Total cost for anaemia is $2,582 
 
Treatment  
 
Survey 
The population of the targeted communities is estimated at 4500 people. We 
estimate 50% prevalence in the first intervention. Assuming a 15% reduction after 
the first intervention, the second intervention will target 35% prevalence which is 
expected to drop to 25%. After the third intervention we expect the prevalence to 
drop to 15% further to 10% after the fourth intervention. The 10% will be use as the 
prevalence over the next one year. As prevalence decreases the number of cases 
treated also decrease and consequently the cost. In the course of the different 
intervention we estimate that we will treat the following number of cases – first 
intervention (0.5*4500) = 2,250, second intervention (0.35*4500) = 1,575, third 
intervention (0.15*4500) = 675 people. Beginning from the forth intervention we 
estimate a prevalence of 10% for remaining interventions giving (0.1*4500) = 450 
cases. Given that after the fourth intervention we have two more interventions, this 
give us (450*2) = 900 cases. The total number of cases to be treated over two years 
is obtained by adding (2250+1575+675+450+900) cases = 5,850 cases. The course 
of treating one case is estimated at $1 giving a total of $5,850. 
 
Home-based management of malaria 
We estimate that an average of 5 cases are additionally identified and treated in 
each community by the volunteers each month over the two years. This gives 7*5*24 
= 840 cases. This will give an additional of 840*$1 = $840. 
Total cost of treatment = ($5,850+ $840) = $6,690 
 
Consumable  
Cost of consumable required such as gloves, safety boxes, silica gel, filter paper and 
PCT reagents will cost $2,024.  PCR will only be considered in case of treatment 
failure. 

25 
 
 
Incentive to children enrolled in the study 
It is estimated that children under five years make up 30% of the population of Pakro 
sub district. This gives (0.3*4500) 1350 children. We will be giving a token of a 
biscuit pack worth $0.25 to each under five child tested. The adults will not be 
included in this package as the free treatment is already a good incentive for the 
community. Cost of incentives for children $0.25* 1350 = $337.5 per survey. The 6 
surveys will cost $337.5*6 = $2,025 
 
Communication Cost 
This is to enable constant communication with the field team. The PI will work closely 
with the team in the field for update on home-base management and follow up of 
treated cases. This is to ensure that adverse effects are captured on time. Stockouts 
will be communicated through SMS. Each volunteer will be given a monthly 
communication credit of $1.26 over two years ($1.26*14*24 = $423.36) while the PI 
will require $30.24*24 = $725.76. This gives a total communication cost over the two 
years of $1,149.12. 
 
Field bags 
Each team member will be given a bag to carry study material. We have 17 team 
members. Each bag will cost $30. Therefore we have 17*$30 = $510.  
 
Community Entry  
We will need to introduce the study to the local authorities. This will be done through 
meetings and durbars with the chiefs. This is to facilitate community understanding 
and ownership of the project. Each of the chiefs will be provided a gift worth $10. 
There are 7 community heads giving (7*$10) = $70. 
 
Home–based management of malaria 
Following each intervention, volunteer workers are required to implement the home-
base management of malaria between surveys. This is to clear residual as well as 
missed cases of parasitaemia in the community. Two volunteers from each of the 
communities (14 in total) who are already involved in IPT in children will carry out 

26 
 
this task. Each volunteer will receive an allowance of $25.15 every three months. For 
a total of 6 interventions we have 14*$25.15*6 = $2,112.6 
 
Longitudinal Cohort study 
The PI and research assistant will spend one week in the community before each 
intervention administering the questionnaire to children enrolled in the cohort study. 
This will give a total of (6*7=42days) per person. The cost is as follows (Drivers 
($25.15*42) =$1,056.3, 1 Research Assistant = ($30.18*42) = $1,267.56, PI 
($37.73*42) = $1,571.56 giving a total of $3,895.5 
 
Personnel 
Personnel cost will be broken into censors, surveys and monitoring cost. During 
each of these activities in the field, the personnel will be paid a daily allowance.   
 
Household Census  
This will be undertaken by 17 personnel in 7 days (14 community volunteers, PI, 1 
research Assistant and 1 driver). The PI, the research assistant and the driver will 
spend an extra one day to plan the census. During the census we will be 
supervising. We estimate that each volunteer will register an average of 46 people 
each day. Each of the team members will receive a daily allowance calculated as 
follows - volunteers ($5.04*14*7days) = $493.92, the driver ($25.15*8) =$201.2, 
Research assistant ($30.18*8) =$241.44 and the PI ($37.73*8) = $301.84 giving a 
total of $1,238.4 
 
Intervention 
A total of 17 personnel will be involved in the interventions which will be conducted 
every four months giving a total of 3 interventions per year and 6 over a two year 
period. The interventions will last 12 days. Each volunteer will spend a total of 72 
intervention days (6*12) over the two years in the field.  The PI, research assistant 
will spend 6 extra days planning each intervention in the field. The cost is as follows 
– volunteers ($5.04*72*14) = $5,060.16, Drivers ($25.15*78) =$1,961.7, 1 Research 
Assistant = ($30.18*78) = $2,354.04, PI ($37.73*78) = $2,942.94 giving a total of 
$12,318.61.  
 

27 
 
Training 
A three days training will be organized for the volunteers before the interventions 
begins. To take part in the training will be 17 volunteers, two resource persons from 
the district health service will provide the training, the PI, a research assistant and 
the driver. This cost will include Transport for participants ($2.5*20*3 =$150), Food 
($3*20*3 = $180), resource persons = ($37.73*2*3 = $224.22), PI ($37.73*3 = 
112.11), research assistant ($30.18*3 = $90.54), driver ($25.15*18 =75.45). 
The total cost for the training is $832.32 
 
Monthly Monitoring visits 
We will undertake field visits to the study area every month to monitor progress, 
each lasting 2 days. This is to verify that the volunteers are doing the right thing, 
discuss challenges faced as well as replenish their stocks of RDT and ACTs. Each 
visit will last two days. Three persons will be involved, the PI, one research assistant 
and a driver. Since 6 of the 24 months will be involved in the surveys, the monitoring 
will take place over the 18 remaining months. The cost is calculated as follows - 
driver ($25.15*18) = $452.7, 1 Research Assistants ($30.18*18) = $543.24, and the 
PI ($37.73*18) = $679.14 giving a total of $1675.08 
The total personnel cost is $15,232.09 
 
Data mining from the hospital records 
The registers of the Health Centre will be consulted and data will be extracted to 
study the trends of malaria admissions in this area over the last 10 years at baseline. 
Then after one year and at evaluation, another study of record will be conducted. 
This will require research assistants or a master student. This is estimated at $2500. 
 
Transportation  
Transport will involve hiring of the vehicle and fuel cost. From Accra to Pakro is 
44.8Km (i.e. 89.6km in and out). There will be an initial trip to censor the area, 6 
intervention trips of 12 days each, 16 monitoring trips of two days each over a two 
year period. 
 
Mapping of the households and identification of people 

28 
 
This will involve one trip of 7 days. As it involves going to all the households we 
estimate 20Km per day. This gives us 89.6Km + (7*20Km) = 226.6Km  
 
Surveys 
We estimate to cover 10Km each day within the Pakro sub district during the surveys 
(12days*10Km+ 89.6Km interventions = 249.6Km for each intervention). We will be 
conducting 6 interventions which gives us 249.6Km*6* = 1,497.6Km 
 
Monitoring visits 
Six of the project months will involve the intervention and therefore monitoring will 
occur over18 months within the study period. This will involve the PI going to the field 
and meeting with the volunteer and replenishing their stocks workers. We estimate to 
cover 15Km in addition to the 89.6Km (in and out) for each trip giving a distance of 
104.6Km. Total distance during monitory is 104.6Km*18 = 1,882.8Km 
Total distance to be covered = (226.6 + 1,497.6 + 1,882.8) km = 3,607Km 
 
Car Hiring Cost  
Currently, the cost for the use of NMIMR vehicle stands at $0.76 per Kilometer. The 
total cost for hiring NMIMR cars is 3,607 * $1 = $3,607.  
 
Fuel Cost 
We estimate to use $300 worth of fuel for each trip undertaken. Given that we are 
going to undertake 6 interventions, 18 monitoring and 1 censor visit, which gives 
(6+18+1)*$300 = $7500 
Total transport cost = $3,607 + $7,500 = $10,567 
 
Rechargeable lamps 
Since these are rural communities and people are involved in different daily 
activities, work would have to start very early in the morning and  extend into the 
night in order to reach out to a greater portion of the community as most of them will 
go out very early and come back late. Seven rechargeable lamps are therefore 
required at $17.64 each giving a total of $123.48. 
 
Statistical analysis  

29 
 
The statistician at NMIMR will enter the household data into software and conduct 
analysis for 20 working days at $150 a day, giving a total of $3000. 
 
Conference and publications 
The findings from this study will be disseminated through conferences, workshops 
and meetings with stakeholders. The PI is also expected to undertake some hands-
on training on economic evaluation and cost benefit analysis. 
 
Consent Form (Attached) 
 
Assent Form and Parental Consent Form (Attached) 
 
Data Collection Instruments  (Attached)