Comprehensive thesis

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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

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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

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Figure: 1.2 Distribution of Malaria over the globe

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Figure 1.3 Malaria cases by country

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Figure: 1.4 Distribution of Plasmodium vivax
Figure: 1.5 Distribution of Plasmodium falciparum

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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’

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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

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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).

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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

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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

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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.

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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. 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. 24
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