1

CHAPTER ONE

INTRODUCTION

Malaria is one of the most devastating diseases in the world. Over 3 billion people live under the

threat of malaria in 24 endemic countries (WHO/UNICEF 2005) and it kills over a million each

year, mostly children (Korenromp, 2004). Malaria is a serious problem and every 30 seconds a

child dies from malaria (WHO, 2009). An estimated one million annual deaths occur from

malaria of which approximately 80% occur in infants and young African children (WHO, 2007).

Similarly Approximately 2.5 million malaria cases are reported annually from South Asia, of

which 76% are reported in India (Kumar et al., 2007).

Malaria in pregnancy (MIP) poses substantial risk to the mother, fetus and neonate. Both

Plasmodium falciparum and Plasmodium vivax infections can cause adverse pregnancy

outcomes, including maternal anemia, low birth-weight and stillbirths due to preterm delivery

and fetal growth restriction (Khan et al., 2005). Pregnant women are more susceptible than non-

pregnant women to malaria, especially in first and second pregnancy (NHS Malaria, 2009). On

the contrary, congenital malaria remains extremely rare both in endemic and non-endemic areas

(Cho et al., 2001). In endemic countries congenital malaria is mainly caused by P. falciparum. In

European countries most cases are due to P. vivax (WHO 2008). Pregnancy-Associated Malaria

(PAM) occurs when red blood cells infected with malaria parasites gather in the placenta

resulting in damage to both mother and developing infant. First-time mothers are particularly

susceptible to PAM whereas women in subsequent pregnancies become protected against PAM.

For the unborn child, maternal malaria increases the risk of spontaneous abortion, stillbirth,

premature delivery and low birth weight, a leading cause of child mortality (Medical News,

2007).

Malaria is responsible for causing great losses of life in the world. The term malaria is used for

the acute or chronic infection caused by Plasmodium parasite. The common symptoms are high

fevers and chills in human beings (Harmening, 1992). The parasite is transmitted from an

infected person to the other person, by the bites of certain female Anopheline mosquitoes

(Sartwell, 1973). The malarial parasite can also be transmitted artificially by inoculation of the

2

infected blood. Man can be infected experimentally with several species of Plasmodium from

apes and monkeys (Davey and Wilson, 1971). Development of resistance in the parasite to

antimalarial drugs and in the vector to insecticides deserves much of the blame for the increase in

the prevalence (Miller and Greenwood, 2002). Over 1.5 billion people live in malarious areas of

the world that lack the administrative, financial, and human resources necessary for control.

Table: 1.1 HIV/AIDS, Tuberculosis and Malaria: The basic facts 2002 (WHO)

Disease Deaths per year New cases per year Percentage in

developing countries

HIV/AIDS 3 million 5.3 million 92%

Tuberculosis 1.9 million 8.8 million 84%

Malaria 1 million 300 million 99.9%

Figure: 1.1 various causes of Deaths

3

Figure: 1.2 Distribution of Malaria over the globe

4

Figure 1.3 Malaria cases by country

5

Figure: 1.4 Distribution of Plasmodium vivax

Figure: 1.5 Distribution of Plasmodium falciparum

6

1.1. Malaria with special reference to Pakistan

According to United Nations World Health Organization (WHO), Pakistan has been classified

as a country with moderate malaria prevalence and relatively well established control programs.

Despite this the disease is estimated to cause at least 50,000 deaths out of an estimated 500,000

reported malaria cases every year (IRIN, 2007). In 2006, the Malaria Disease Surveillance

Program in Pakistan registered 3.5 million slides and 127,825 confirmed cases of malaria with an

annual parasite incidence (API) of 0.8 cases per 1000 population. However the actual case load

is estimated to be 5 times higher since public-sector diagnostic facilities cover 20-30% of the

patient load, and the remaining gets their treatment from the private sector (Kakar et al., 2010).

The estimated number of annual malaria cases in Pakistan is 1.5 million (World Malaria Report,

2005). Among the four species of Plasmodium known to infect human, Plasmodium vivax and

Plasmodium falciparum are prevalent in Pakistan (Murtaza et al., 2004). The incidence of

malaria has strikingly increased during the last ten years and the relative rate of occurrence of P.

falciparum has increased from 45% in 1995, to 68% in 2006 amongst malaria infection (Ghanchi

et al., 2011).

In 2004, Punjab and the Azad Jammu and Kashmir (AJK) reported the lowest figures of malaria

cases while Balochistan and the Federally Administered Tribal Areas (FATA) reported the

highest frequency. Sindh and Khyber Pakhtunkhwa reported moderate figures in the same period

(World Malaria Report 2009).

Transmission of malaria in Pakistan is seasonal and occurs mainly after the July-August

Monsoon (Rowland et al., 2000). High rainfall in autumn and above average temperatures in

November-December (a distinct trend in recent years) are key risk factors that enhance or

prolong the transmission seasons in Pakistan (Bouma et al., 1996).

1.1. Malaria with special reference to Afghan Refugees’

Afghan refugees have resided in Pakistan for over 3 decades. Over 3 million initially sought

refuge after the Soviet invasion in 1979. Half were able to return home to safe areas in the early

1990’s, after the fall of the Soviet-backed regime. But in the aftermath of 9/11 terrorist incidents

in the United States, the number of refugees entered to Pakistan had swollen the refugees’

7

population to its former size. The refugees presently inhabit over 200 camps on the western

border of Pakistan, The camps were sighted on marginal lands and many water logged or

adjoining rice cultivation, and hence prone to mosquito breeding (Rowland and Nosten, 2001).

Afghan refugees, being more susceptible, are at high risk of malaria infection in Pakistan rather

than they brought a high infection load from Afghanistan (Suleman, 1988). At the height of the

epidemic among refugees in 1990, over 150,000 cases were being diagnosed and treated each

year by the combined health care services of the United Nation High Commission for Refugees

(UNHCR), the government of Pakistan and non-governmental organizations (NGO’s) (Rowland,

1999). About 30% cases were caused by Plasmodium falciparum and the rest by Plasmodium

vivax (Rowland et al., 2001). The trait glucose-6-phosphate dehydrogenase (G-6-PD) deficiency

in Afghan refugees and in a local community in the North-West Frontier Province, Pakistan, is

the most common among Pathan and Uzbek refugees. The type of G-6-PD deficiency in Pathans

could cause severe haemolytic crisis (Bouma et al., 1995).

1.1. Malaria Prevention and Control in Afghan Refugees’

To reduce the burden of malaria UNHCR and WHO is running various campaigns by providing

treatment as well as providing insecticide treated materials like tent spraying, insecticide treated

bed nets (ITN), Permethrin-treated clothing or bedding, indoor spraying of residual insecticide,

livestock sponging and other personal protective methods.

1.2. The Parasite and its Life Cycle

The malaria parasite is a mosquito- transmitted protozoan. Plasmodia are sporozoan parasites of red blood

cells transmitted to animals (mammals, birds, reptiles) by the bite of mosquitoes. There are four species of

Plasmodia (P. falciparum, P. vivax, P. ovale and P. malariae) which can cause malaria in humans and

lead to disease (Gilles, 1987). These species are found in all countries extending from 40 degree south to

60 degree north. The tropical zone is the endemic home of all malarial parasites except P. malariae which

occurs in subtropical zone. P. vivax is the prevalent species of temperate zone. The distribution of P.

ovale has mainly been reported from East Africa, West Africa especially Nigeria and Philippines. While

In sub-Saharan Africa most malaria episodes are caused by P. falciparum, which is the agent of the most

severe and fatal malaria disease.

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Transmission of the Plasmodium parasite is mainly from person to person through the bite of a

female Anopheles mosquito. Rarely transmission can be through accidents, such as transfusion,

inoculation of infected blood from one person to another, or transfer through the placenta from

an infected mother to her unborn child.

The malaria parasite has a unique life-cycle adapted to man over the years. It passes its life cycle

in two different hosts, in man and in female anopheles mosquito, with three reproductive phases.

1.4.1. In Mosquito (Sexual Phase)

Though the sexual cycle of malarial parasite first start in the human with the maturation of some

merozoites into gametocytes but a single cycle of sexual reproduction also occur in the female

mosquito called as sporogony, which produces sporozoites that infect man. At 24°C sporogony

takes 9 and 21 days in P. falciparum and in P. malariae respectively. When the infected

mosquito bites man it injects the sporozoites into the blood.

1.4.2. In Human (Exo-erythrocytic Phase)

The sporozoites then travel to the liver in the blood where the next phase, a single cycle of

asexual reproduction) takes place in the human Liver cell called hepatic schizogony or pre-

erythrocytic phase producing merozoites. This cycle lasts approximately 8 days in P. vivax, 6

days in P. falciparum and 9 days in P. ovale. The micro-merozoites enter the blood when the

liver cells burst and invade the red blood cells while the macro-merozoites re-enter the liver

cells. Relapse can occur in case of P. vivax and P. ovale as in these two parasites sporozoites can

remain in the liver for several years in the form of hypnozoites, while in case of P. falciparum

and P. malariae it’s omitted and no relapse occur.

1.4.3. In Human (Erythrocytic Phase)

The third or final phase known as erythrocytic schizogony or erythrocytic cycle consists of

several cycles of asexual reproduction (each cycle lasting about 48 hours for P. falciparum, P.

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ovale and P. vivax, but 72 hours for P. malariae) which takes place in red blood cells. This phase

produces new merozoites during each cycle which invade new red blood cells and start the

erythrocytic cycle again.

However, due to unknown mechanism yet some of these merozoites differentiate into male and

female gametocytes, which are taken up by the blood-sucking female anopheles to start the next

sporogonic cycle in the mosquito.

1.5 Pathogenesis

1.5.1 P. vivax Pathogenesis

Though P. vivax does not cause death but cause febrile reactions/paroxysms, severe anaemia,

recrudescences, relapses or re-infection occur over a course of years and lead to a state of

cachexia or chronic ill-health associated with splenomegaly.

1.5.2 P. falciparum Pathogenesis

P. falciparum also causes irregular febrile paroxysms and due to high parasitemia can cause

severe hemolytic anaemia, cerebral malaria and in severe cases spleen rupture. In case of

pernicious malaria (acute P.falciparum malaria), agglutination of parasitized erythrocytes (more

than 5% in this case) in the capillary blood vessels of the internal organs lead to its blockage,

consequent upon decreased effective circulating blood volume, a condition arises which not if

effectively treated threatens the life of patient within 1 to 3 days. In case of blackwater fever by

P. falciparum which occurs in previously infected subjects, is characterized by sudden

intravascular haemolysis followed by fever and haemoglobinuria which can lead to renal failure

(uraemia), acute liver failure and circulatory collapse.

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Table 1.2 Disease Severities and Duration

P. vivax P. ovale P. malariae P. falciparum

Incubation

Period (days)

8-27 8-27 16->40 6-25

Severity of Initial

Paroxysms

Moderate-severe mild Mild-moderate Severe

Average

Parasitemia

(per mm3)

20,000 9,000 6,000 50,000-500,000

Maximum

Parasitemia

(per mm3)

50,000 30,000 20,000 2,500,000

Typical

Symptom

Duration

(untreated)

3-8 weeks 2-3 weeks 3-24 weeks 2-3 weeks

Maximum

Infection

Duration

(untreated)

5-8 years 12-20 months 20-50 years 6-17 months

Anemia ++ + ++ ++++

Other

Complications

renal cerebral

Aims and Objectives

Objectives of the present study is to find out the prevalence of malaria infection and responsible

species of Plasmodium in Afghan refugees camp, Chakdara, District Dir lower, Khyber

Pakhtunkhwa, Pakistan. No study on the prevalence of malaria infection has far been carried out

at this camp yet.

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CHAPTER TWO

LITERATURE REVIEW

Owing to the breakdown of health systems, mass population displacements, and resettlement of

vulnerable refugees in camps or locations prone to vector breeding, malaria is often a major

health problem during war and the aftermath of war. During the initial acute phase of the

emergency, before health services become properly established, mortality rates may rise to

alarming levels. It is also a major cause of morbidity and mortality worldwide, especially in

young children. It is a major parasitic disease that can be prevented and treated. Several efforts

based on protection of individuals, households at community level (Warrell et al, 2002) have

been initiated to ensure morbidity and mortality due to malaria is reduced. Currently several

proven and cost effective malaria control interventions have been largely initiated in malarious

areas. These include prompt treatment with Artemisinin Based Combination Therapy (ACTs),

high coverage with LLITNs, Intermittent Preventive Therapy in pregnancy (IPTp) and

Insecticide Residual Spray (IRS). These measures have significantly proven to reduce clinical

and risks of malaria infection particulary in pregnancy and children under five years who are

vulnerable groups to malaria.

During the last decade, research on malaria in refugee camps on the Pakistan-Afghanistan and

Thailand-Burma borders has led to new methods and strategies for malaria prevention and case

management, and these are now being taken up by international health agencies. The priority

interventions to reduce death rates in newly established camps are provision of clean water, food,

sanitation, shelter, and communicable-disease control (Simmonds et al., 1983; Toole and

Waldman, 1990, 1997; Anon., 1997). As security and access to refugees improve during the post

emergency phase, improved health provision becomes feasible. But refugees usually remain

vulnerable and assistance may be required until conditions favor to return home, which may take

several years in chronic situations (Anon., 1997).

Development of drug resistance in malarial parasite has also become a serious factor nowadays

in Pakistan as well as in the whole world including Afghan refugees. Compounding the problem

is the development of chloroquine resistance which, since the first reports in the mid-1980s (Fox

12

et al., 1985), has spread throughout the country (Shah et al., 1997; Rowland et al., 1997b). Most

(90%) of the cases of P. falciparum malaria among the Afghan refugees in western Pakistan are

sensitive to sulfadoxine-pyrimethamine (Rowland et al., 1997a) and the P. vivax malaria in this

population is still sensitive to chloroquine (Rowland and Durrani,1999).

Afghans are still sometime accused of bringing malaria to Pakistan (Kazmi and Pandit, 2001).

Refugees everywhere are frequently treated as scapegoats. The reality is that the Afghan arrivals

in the early 1980’s succumbed to malaria transmitted within Pakistan (Suleman, 1988). It was

speculated at that time that poverty-stricken refugees were unable to benefit from zooprophylaxis

as they lacked the domestic animals necessary to divert mosquitoes away from humans (De

Zulueta, 1989). It later transpired that the opposite was true: refugees who owned livestock, and

camps with a high proportion of livestock-owning families, had a higher prevalence of malaria

than people or camps with fewer domestic animals (Bouma and Rowland, 1995). The

explanation seems to be that cattle provide mosquitoes with an easy source of blood, which lead

to inflated vector populations (Nalin et al., 1985), a significant proportion of which is attracted to

feed on people sleeping outdoors close to their animals (Hewitt et al., 1994). Nowadays most

refugee families own livestock and malaria prevalence seems to differ little between Afghan and

neighboring Pakistani communities (Bouma, 1996).

13

CHAPTER THREE

MATERIALS AND METHODS

3.1. Location:

Chakdara is a town in Lower Dir District of Khyber-Pakhtunkhwa. It is located north

of Malakand on the north bank of the Swat River, in a commanding position near the entrance

to Swat District and at the entrance to Lower Dir. It is about 130 km from Peshawar and 40 km

away from Saidu Sharif, It’s the gateway to Lower Dir District.

Co-ordinates are: 34°39′N 72°02′

Figure: 3.1 Google Earth satellite image of District Chakdara

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This study was conducted during July, 2012 to June, 2013 at Afghan refugees’ camp, Chakdara,

District Dir lower, Khyber Pakhtunkhwa, Pakistan to record and screen the species of malarial

parasites from the blood of human patients suffering from malaria.

The patients were divided into 3 age groups: 1-4 years of age, 5-14 years of age and 15 years and

above.

3.2 Materials:

70% Alcohol, Surgical cutting needle, glass slide, spreader, pencil or needle, Leishman’s stain,

Giemsa’s stain and a microscope.

3.3 Methods:

Two types of blood films were prepared a thin blood film and a thick blood film.

3.3.1. Preparation of thin blood film:

The surface of the film remains even and uniform and the margins of the film don’t extend to the

sides of the slide. The “tails” end near about the Centre of the slide. It consists of a single layer

of RBC (Red Blood Cells).

1) The pulp of the finger of the suspected person was wiped out with 70% alcohol, allowed

to dry and then pricked with surgical cutting needle.

2) A drop of blood not larger than a pinhead was taken on a grease free clean slide, at a

distance of about half an inch from the right end.

3) A spreader was held at an angle of 45 degrees in contact with the drop of blood; then

lowered it to an angle of 30 and pushed gently to the left, till the blood was exhausted.

The tails formed by the film ended near the Centre of the slide.

4) The film was allowed to dry and labeled by writing across the film with a sharp pointed

pencil.

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3.3.1.1 Staining

3.3.1.2 With Leishman’s Stain:

1) Leishman’s stain was poured from a drop bottle over the dried film and allowed it to

remain for 30 seconds.

2) Then diluted the stain with twice its volume of distilled water which was either neutral or

slightly alkaline (pH 7-7.2) and covered to prevent it drying.

3) This diluted stain was allowed to remain on the slide for 10-15 minutes.

4) Then the slide was held under an open tap and the stain was flushed in a gentle flow of

water. The reverse side of the slide was cleaned by rubbing it well with wet and squeezes

cotton wool.

5) The slide was kept in an upright position with film side inwards to drain and dry.

6) The dried stained film was examined with 1/12 inch oil immersion lens.

3.3.1.4 With Giemsa’s Stain:

This stain was purchased as a ready-made solution. The method of staining is as follows.

1) The film was first fixed with pure methyl alcohol or ethyl alcohol for 3 to 5 minutes and

allowed to dry.

2) Giemsa’s stain was diluted by adding 1 drop to each 1 ml of distilled water, neutral or

faintly alkaline (pH 7-7.2).

3) The diluted stain was poured over the film (about 5ml per film) and kept for 30 to 45

minutes.

4) The slide was then flushed in a gentle flow of tap water, after which it was placed in an

upright position with the film side inward to drain and dry.

5) The stained film was examined under 1/12 inch oil immersion lens.

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3.3.2. Preparation of thick blood film:

A big drop of blood was taken on a slide and spread using needle or with the corner of another

slide to form an area of a half-inch square; or 4 small drops of blood were taken and the corners

of the drops were joined by a needle. The film was dried in a horizontal position and kept

covered by a petri dish. As in dry climates the slide takes about 30 minutes to dry completely at

room temperature so it could be accelerated by putting the slide inside an incubator.

3.3.2.1 Staining:

This was carried out with Leishman’s or Giemsa’s or Field’s stain; if it is desired to use the

former two stains, the slide was dehaemoglobinised before staining.

Dehaemoglobinisation was carried out:

1) With glacial acetic acid and tartaric acid mixture. The film was flooded with the mixture

and as soon as dehaemoglobinisation was complete (indicated by the greyish white colour

of the film), the fluid was drained off by tilting. It was then fixed with methyl alcohol for

3 to 5 minutes. The slide was then washed thoroughly with neutral or slightly alkaline

distilled water so that every trace of acid was removed.

2) In distilled water the film was placed in a vertical position in a glass cylinder for 5 to 10

minutes. When the film became white, it was taken out and allowed to dry in an upright

position.

After dehaemoglobinisation the film was stained with Leishman’s stain or Giemsa’s stain in the

same way as the thin film.

Field’s stain can also be used as a quick method in making thick blood smear which was not used

during this research.

However thin blood films were given priority over thick blood films as in thick blood films the

morphology of the parasite become distorted and make difficulties in the identification of the

parasite. The plus point of thick blood film is that it can give us a rough idea about parasitemia

due to large amount of blood as compared to thin blood film.

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3.3.3. Techniques:

Malaria cases were detected by adopting two ways (Manson-Bahr and Bell, 1987).

3.3.3.1 Passive case detection (PCD):

The technique wherein blood films were taken from the patients coming to a health station with

symptoms of shivering and fever or a history suggestive to malaria.

3.3.3.2 Active case detection (ACD): The technique in which home visits were made to

persons with signs or symptoms of malaria and blood films both of thick and thin smear were

prepared. For ACD house visits of suspected patients of malaria were made with the help of

head/Malik of these localities. Blood slides were taken back to the laboratory where they were

stained in Giemsa’s stain following the technique described by Manson-Bahr and Bell (1987).

Identification of species of malarial parasites was made from the keys furnished by Sood (1989)

and Paniker-Jarayam (2002).

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CHAPTER FOUR

RESULTS

A total number of 958 blood smears were prepared from the age group 1 year to 15 years and

above in Afghan refugees camp, Chakdara, District Dir lower. The overall prevalence of

Plasmodium recorded was 25.5% which was only of Plasmodium vivax and none of the other

three species Plasmodium falciparum, Plasmodium Ovale, Plasmodium malariae or mixed

infection was detected, as mix infection of Plasmodium vivax and Plasmodium falciparum was

observed in Multan district by Yar et al., (1998).

Table3.1: Month wise and overall prevalence of malaria infection in Afghan refugees’

camp, Chakdara, District Dir lower.

Month No of slides

examined

Total No of

Positive

(%)

Plasmodium

vivax (%)

Plasmodium

falciparum

(%)

July 2012 177 57(32.2) 57(100) 0(0)

August 189 51(26.9) 51(100) 0(0)

September 87 21(24.1) 21(100) 0(0)

October 120 40(33.3) 40(100) 0(0)

November 63 19(30.1) 19(100) 0(0)

December 30 8(26.6) 8(100) 0(0)

January

2013

27 6(22.2) 6(100) 0(0)

February 19 2(10.5) 2(100) 0(0)

March 21 6(28.5) 6(100) 0(0)

April 65 10(15.3) 10(100) 0(0)

May 90 9 (10) 9(100) 0(0)

June 70 15(21.4) 15(100) 0(0)

Total 958 244(25.5) 244(100) 0(0)

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From Table 3.1 it is evident that slide positivity rate SPR is higher in October (33.3%) and in

July (32.2%) probably due to infrequent autumn rain (enhances transmission seasons) and

regular Monsoon rains respectively. In Pakistan July is generally considered to have high

prevalence rate of malaria but from the table it can be noticed that SPR is the highest for the

month of October that is (33.3%) and this is probably due to weather shift and prolonged

(infrequent) rainy seasons in this locality. The SPR in December, January, February and March

is less due to cold and non-suitable weather for Malaria infection of which February shows the

least SPR of 10.5%. However May shows the least SPR of 10% and April 15% probably due to

moderate weather in these months. No case of Plasmodium falciparum was found in any month

which is the fruit of the successful hectic efforts of UNHCR to eradicate malarial infection,

particularly that of Plasmodium falciparum. Although previously Plasmodium falciparum was

also detected in few cases according to the BHU (Basic Health Unit) Chakdara archives (A

single case of P.falciparum detected was a girl named Nadia in 2010), but as soon it was reported

to UNHCR, emergency campaigns were run throughout the camp by providing insecticide

treated materials such as ITNs, Indoor residual spraying and livestock sponging etc. which led to

its local extinction in the camp. So after 2010 no case of P. falciparum has yet been reported in

this camp which is a good sign.

Table: 3.2 Age wise overall prevalence of malaria infection in Afghan refugees camp,

Chakdara, District Dir lower.

Age (Years) No of slides

examined

Total No of

+ve

Overall

Infection (%)

Infection with

Plasmodium

vivax (%)

Infection with

Plasmodium

falciparum (%)

1-4 290 65 22.4 100 0

5-14 300 91 30.3 100 0

>=15 368 88 23.9 100 0

Total 958 244 25.5 100 0

From table 3.2 it can be noted that SPR is the highest for age 5-14 that is 30.3 % (91/300) while

the second highest SPR is for age 15 and above that is 23.9% (88/368) and the lowest SPR

22.4% (65/290) is for 1-4 years of age. The highest SPR for age 5-14 years of age is probably

20

due to their play age and constant and continuous exposure to such places which are suitable

mosquito breeding sites. The least SPR for age 1-4 is the traditional care of these children by

their parents mostly mothers i.e. wrapping them in clothes and abstaining them from going out of

their homes probably in night times. However no infection of Plasmodium falciparum is seen for

any age group.

Table: 3.3 Month wise and Sex wise prevalence of malaria infection in Afghan refugees’

camp, Chakdara, District Dir lower.

Month Total No of +ve Male Female

P.

vivax

(%)

P.

falciparum

(%)

P.

vivax

(%)

P.

falciparum

(%)

July 2012 57 23(40.3) 0(0) 34(59.7) 0(0)

August 51 18(35.2) 0(0) 33(64.7) 0(0)

September 21 8(38.0) 0(0) 13(61.9) 0(0)

October 40 20 (50) 0(0) 20(50) 0(0)

November 19 9(47.3) 0(0) 10(52.6) 0(0)

December 8 4 (50) 0(0) 4(50) 0(0)

January 2013 6 3 (50) 0(0) 3(50) 0(0)

February 2 0 (0) 0(0) 2(100) 0(0)

March 6 1(16.6) 0(0) 5(83.3) 0(0)

April 10 3 (30) 0(0) 7(70) 0(0)

May 9 4(44.4) 0(0) 5(55.5) 0(0)

June 15 6 (40) 0(0) 9 (60) 0(0)

Total 244 99(40.6) 0(0) 145(59.4) 0(0)

Overall females are more infected with malaria with 59.4% prevalence as compared to males

with 40.6% prevalence. The prevalence is more in female more specifically in the month of July,

August and September which are the months of Monsoon rains. Reasons for high prevalence in

21

female is that they continuously remain in touch with mosquito breeding places by doing

household tasks like washing clothes and dishes outdoor in such places where there is stagnant

water. They also don’t have proper sanitation system in their homes. They also remain in touch

with cattle, majority sleeping in cattle rooms and as Anopheles also feed on blood of cattle so

they get much exposure to malarial infection as compared to males. Also due to poor literacy

rate, unwise or no use of UNHCR provided ITNs and other insecticide treated materials both the

genders, most particularly females are at high rate of getting malarial infection.

22

CHAPTER FIVE

DISCUSSION

In the present study the prevalence only of Plasmodium vivax 25.5% (244/958) was observed

while other research workers reported both Plasmodium vivax and Plasmodium falciparum from

different parts of Pakistan. Many research workers reported high prevalence of Plasmodium

vivax in district Multan (60.5% P. vivax, 37.2% P. falciparum), Muzaffarabad (90.4% P. vivax,

0.6% P. falciparum), Buner (5.7% P. vivax,1% P. falciparum), Quetta (66.8% P. vivax, 30.7% P.

falciparum), Dera Murad Jamali (76.2, 73.5, 75.8% P. vivax, 23.8, 26.4, 24.1% P. falciparum),

Qilla Abdullah (97.3, 100,100% P. vivax, 2.6, 0, 0% P. falciparum), Noshki (98.1, 79.2, 86.5%

P. vivax,1.8, 20.7, 13.4% P. falciparum), Dalbandin (98.1,64.8, 72.2% P. vivax, 1.8, 35.1,27.7%

P. falciparum), Qilla-Abdullah (62.2% P. vivax, 37.7% P. falciparum), Mastung and Khuzdar

(52.6, 69.8% P. vivax, 47.3, 30.1% P. falciparum), Kohlu (58.9% P. vivax, 41% P. falciparum),

Zhob (51.8% P. vivax, 48.1% P. falciparum), Kharan (88.6% P. vivax, 11.3% P. falciparum),

Sibi (72.3% P. vivax, 27.6% P. falciparum) (Yar et al.,1998; Jan & Kiani,2001; Mohammad &

Hussain,2003; Sheikh et al., 2005; Malaria Control Program, 2004,2005,2006; Yasinzai &

Kakarsulemankhel, 2007a,2007b, 2008a,2008b, 2008c,2008d respectively).

The prevalence of malaria in Afghan refugees’ school going children of Mardan district was very

higher 7.91% (Jan and Kaleem, 1993). Similarly Jan and Kiani (2001) found 8.4% and 73.6%

Plasmodium vivax prevalence in the patients of the age group of 11-20 years and 21 years and

above, respectively, in Kashmiri refugees settled in Muzaffarabad. Iqbal et al., (1998) noted high

incidence of malaria in N.W.F.P with higher mortality and complication in Plasmodium

falciparum malaria probably because patients’ studies came from far flung areas of N.W.F.P and

Afghanistan in advanced stage of the disease. The majority of the refugees settled in N.W.F.P,

The highest incidence of malaria (6.71%) was noted in N.W.F.P in 1990.

Mixed infection of P. vivax and P. falciparum was not observed in the present study, but mixed

infection of 2.3% was observed in Multan district by Yar et al. (1998). However, the same 2.3%

was observed in Quetta district (Sheikh et al., 2005). During present study, no case of P.

malariae or P. ovale infection was observed, and the same were the observations of Yar et al.

(1998) in Multan.

23

CHAPTER SIX

CONCLUSION

No positive slide of Plasmodium falciparum as well as mixed infection was observed, however

prevalence of Plasmodium vivax was recorded to be 25.4%. The incidence in women was higher

(59.4%) as compared to men (40.6%). Children of 5-14 years of age are more effected (30.3%)

as compared to that of 1-4 years of age (22.4%) and 15 years and above (23.9%). The incidence

rate of infection increases from March to November.

Although Plasmodium falciparum is totally absent in Afghan refugees camp Chakdara, still

prevalence of Plasmodium vivax, the prolonging of transmission seasons due to infrequent rains

and high temperatures poses a great danger for its inhabitants. Although Pakistan malaria control

program and international agencies like WHO and UNHCR have a great focus over malaria

control, still they have to do more to lessen malaria burden to its least. UNHCR which is mostly

concerned with Afghan refugees have to provide insecticide treated materials like tent spraying,

insecticide treated bed nets (ITN’s), Permethrin–treated clothing or bedding, indoor spraying or

residual insecticide and livestock sponging but the most important factor is education of masses

about malaria as literacy rate in Afghan refugees is very less, which would help to deduct

malaria infection to the least in the future, with the goal to completely eradicate the infection.

24

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