TREATMENT FAILURE OF MALARIA CONTROL IN PAKISTAN

INTRODUCTION DEFINITION

“An infective disease caused by sporozoan parasites that are transmitted through the bite of an infected Anopheles mosquito; marked by paroxysms of chills and fever.”

Malaria is the most important of the parasitic diseases of humans present in 107 countries and areas at risk of transmission are close to 50 percent of the world’s Population.1

More than 3 billion people live in malarious areas and the disease causes between 1 million and 3 million deaths each year .2

Recent estimates of the global falciparum malaria morbidity burden have increased the number to 515 million cases .

Almost 5 billion clinical episodes of malaria occur in endemic areas annually, with more than 90 percent of this burden occurring in Africa .2,3

PAKISTAN SITUATION

PAKISTAN SITUATION Malaria is the second most prevalent and devastating disease in the

country (HMIS 2006). Transmission is seasonal and prone to epidemic outbreaks in certain geographical areas of Baluchistan NWFP and sindh. The disease is now emerging as prominent health problem in FATA.

Major malaria transmission season in Pakistan is post-monsoon (Sep-Nov) however along the costal areas and western border areas of country , the disease prevails throughout the year.5

Estimated number of annual malaria episodes in Pakistan is 1.5 million. The primary vector species are A. culicificies and

A. stephensi. P. falciparum and P. vivax are widely distributed in the country.

STRATIFICATION OF BURDEN BY CASES REPORTED

Malaria Occurrence (API) by district

More than 3.5

1.6 – 3.5

0.5 – 1.5

Less than 0.5

No data available

MAGNITUDENo. of reported cases (source: directorate of national malaria control program)

YEAR 1998 1999 2000 2001 2002 2003 2004 2005

REPORTED CASES

73516 91774

82526

104003

101761

125152

126719

127825

(% age increase

42.4)

In 2005, falciparum malaria constituted 33% of reported confirmed malaria cases. In the same period, 46% of cases were reported from Baluchistan province with highest proportion of falciparum malaria, i.e. 44%.

CAUSES OF TREATMENT FAILURE OF MALARIA CONTROL IN PAKISTAN

AT DIAGNOSIS STAGE

Quality of microscopy services

Maintainance of lab equipment

Lack of trained staff AT PATIENT LEVEL

Patient compliance and practice of self medication

DRUGS

overprescription

shortage at facility

unofficial drug sellers in private sector

The high costs of drugs may lead people to unofficial sources, which will sell a single tablet instead of a complete course of treatment, and subsequently to increased, often irrational demand for more drugs and more injections. Increasingly people are resorting to self-medication for malaria .

DRUG RESISTANCE

Drug resistance in Bannu district, a malaria-endemic area in Pakistan, molecular-based analyses were undertaken . all (100%) P. falciparum isolates exhibited the key chloroquine resistance mutation,, which is also associated with resistance to amodiaquine. These results indicate an emerging multi-drug resistance problem in P. vivax and P. falciparum malaria parasites in Pakistan.9

  DATA AVAILABILITY

In 2006 Malaria Disease surveillance program registered 3.5 million slides prepared and 127,825 confirmed cases of malaria with Annual Parasite Incidence (API) of 0.8 cases per 1000 populations. 11. However according to another estimate the actual case load may be 5 times higher since public sector diagnosis facilities does not cover more than 20-30% of the attending patients and other 80% which get their treatment from private sector .

Continued…….

Continued ………

LACK OF COMMUNITY AWARENESS Lack of awareness about hygiene and sanitation practices.

Communities are unable to manage these health problems due to lack of knowledge about the causes of these diseases and access to appropriate health services. 12,19

INSECTICIDE RESISTANCE

Insecticide resistance (karachi study) pyrethroid ,malathion in the mosquitoes in pakistan

Continued……

KEY DETERMINANTS OF MALARIA

PROJECT (TEST PROJECT)

AIM ELIMINATION OF MALARIA FROM

PAKISTAN .OBJECTIVE To decrease the morbidity and mortality

associated with malaria in LORALAI district of Balochistan

To decrease treatment failure of malaria by 50% in LORALAI in 3 years

LORALAI

EXISTING STRATEGY.

SURVEILLANCE

MULTIPLE PREVENTION

EPIDEMIC PREPAREDNESS

BCCOPERATIONAL

RESEARCH

CASE MANAGEMENT

PARTNERSHIPBUILDING

MALARIACONTROL

STRATEGIES

PREVENTIVE

CURATIVE

BCCPersonal protectionVector controlEarly diagnosis /treatment

•RDT use promotion•Training of staff (microscopists)•Upgrading infrastructure(equipment)

•Public private partnership•Coordination of different departments(planning, environment,sanitation & meteriology)•Use of neo pesticides

•Drug policy change

•Registration of drugs by pharmacist

•sale on prescription

Malaria surveillance centersResearch centers.

PRIORITIES 1- Community based interventions: Arranging health education sessions weekly at the

centers/tents about available options for protection.Distribution of health education material to the

people (availability & use of LLIN ,ITN retreatment).Meeting with influential persons, imams and select

community volunteers from each area.Training of community based service provider like

LHW.School teachers and students to be invited to

attend the sessionsDisplay of charts and health education material at

sessions

BEHAVIORAL CHANGE COMMUNICATION

WE ARE DETERMINED TO ERADICATE MALARIA

Newspaper & local print media(danger signs)Wall painting with slogans Announcements in mosques by religious people.Weekly based program on FM radio stations/Tv plays (buzz & bite).

2- CURATIVEInitially after identification of the high risk clusters areas within the district

RDT will be given to the BHU. Staff will be trained for the use of RDT.Drug policy change regarding dispensing at private and public

sector(registration)Drug inspectors to check the quality and quantity from the registration

registers.Provision of revised guidelines for malaria control at every BHU(ban on

monotherapies)

Continued…….

3-Meetings for the Coordination between departments like Meteriology planning ,environment, agriculture for the sharing of information and thus helping in future preventive strategy for malaria.

4-Meetings for the Sharing of data between private and public sector regarding confirmed cases and drug use.

5-Replacement of organophosphates by neopesticide (neem)

6-Upgrading of Malaria control centre (surveillance +research)

Continued….

COST OF PROJECT

STRATEGY COMPONENTS

AMOUNT SPEND IN MILLIONS (rupees)

EARLY DIAGNOSIS AND TREATMENT 3 MILLION

MULTIPLE PREVENTION

5 MILLION

BCC

8 MILLION

INSTITUTIONAL STRENGTHENING

2 MILLION

CONTINGENCIES 1 MILLION

TOTAL 19MILLION

MONITORING PROCESS INDICATORS

No malaria cases per OPD  Proportion of mothers trained on prevention of malaria in the

communities. Proportion of HF with copies of National Antimalarial treatment

Guidelines. Number of vector control teams established. Number of vector control teams strengthened. # of LLIN distributed to children under five. # of LLIN distributed to pregnant women  # of Malaria microscopy slides taken # of Rapid diagnostic tests (RDTs) taken %age of Malaria cases that are laboratory confirmed # of Functional sentinel sites for monitoring antimalarial drug

resistance # of Functional sentinel sites for monitoring insecticide resistance. 

EVALUATION IMPACT INDICATORSmalaria specific mortality ratemalaria infection prevalencemalaria case ratemalaria incidence EFFECT INDICATORSKAP SURVEY AFTER 3 YEAR

REFERENCES 1-Hay and others 2004; WHO 2005 2-(Breman 2001; Breman, Alilio, and Mills 2004; Carter and Mendis 2002; Snow and others 1999, 2003;

Snow, Trape, and Marsh 2001). 3-MALARIA SURVELLANCE REPORT 2003,pakistan 4-WWW.WHO.INT/COUNTRIE( WHO, Regional office for eastern meditteranean ,Rollback malaria) 5-dr.humayon rather guidelines of malaria control,ministry of health 6-http://202.83.164.26/wps/portal/Moh 7-WWW.WHO.INT/COUNTRIES/PK dated 30th oct2009 8-: Foster SD, Pricing, distribution, and use of antimalarial drugs”, Bull World Health Organ. 1991;69(3):349-

63. 9-- Khatoon L, Baliraine FN, Yan G,” Prevalence of antimalarial drug resistance mutations in Plasmodium

vivax and P. falciparum from a malaria-endemic area of Pakistan”. Department of Biochemistry, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, Pakistan.

-10- http://www.pakistan.gov.pk/divisions 11http://phkn.org.pk 12- M. J. Bouma, C. Dye AND H. J. van der Kaay , “Falciparum Malaria and Climate Change in the

Northwest Frontier Province of Pakistan” Medecins Sans Frontieres-Holland, Amsterdam, The Netherlands; London School of Hygiene and Tropical Medicine, London, United Kingdom; Laboratory for Parasitology, Medical Faculty, University of Leiden, Leiden, The Netherlands. Am. J. Trop. Med. Hyg., 55(2), 1996, pp. 131-137.

13 Shah I, Rowland MMehmood P, Mujahid C Razique F, Hewitt S,Durrani N “Chloroquine resistance in Pakistan and the upsurge of falciparum malaria in Pakistani and Afghan refugee populations”National Institute of Malaria Research and Training, Lahore, Pakistan. malaria@msfhni.psw.erum.com.pk

14-http://www.pakistan.gov.pk/divisions 15-WHO report 2008 

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