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
 MAGNITUDE
No. of reported cases (source: directorate of national
malaria control program)

YEAR 1998 1999 2000 2001 2002 2003 2004 2005

REPORTED 126719
CASES
73516 91774 82526 104003 101761 125152 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 .
 Continued…….
 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
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
PARTNERSHIP MULTIPLE
BUILDING PREVENTION

MALARIA
CONTROL
CASE
EPIDEMIC
MANAGEMENT
PREPAREDNESS
OPERATIONAL
BCC
RESEARCH
 STRATEGIES
PREVENTIVE CURATIVE

BCC •RDT use promotion

Personal protection •Training of staff
Vector control (microscopists)
Early diagnosis /treatment •Upgrading
infrastructure(equipment)

•Public private partnership

•Coordination of different •Drug policy change
departments(planning,
environment,sanitation & •Registration of drugs by
meteriology) pharmacist
•Use of neo pesticides
•sale on prescription

Malaria surveillance
PRIORITIES
BEHAVIORAL CHANGE COMMUNICATION

WE ARE DETERMINED TO ERADICATE MALARIA

 Continued…….
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- CURATIVE
Initially 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)
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 INDICATORS
malaria specific mortality rate
malaria infection prevalence
malaria case rate
malaria incidence

EFFECT INDICATORS
KAP 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
THANKYOU