http://informahealthcare.com/mby ISSN: 1040-841X (print), 1549-7828 (electronic) Crit Rev Microbiol, Early Online: 1–6 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/1040841X.2014.973368
REVIEW ARTICLE
Current situation and challenges in implementing Malaria control strategies in Pakistan N. K. Ghanchi1, S. Shakoor1, A. M. Thaver2, M. S. Khan2, A. Janjua2, and M. A. Beg1 Department of Pathology and Microbiology, Aga Khan University, Karachi, Pakistan and 2Medical College, Aga Khan University, Karachi, Pakistan
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Abstract
Keywords
Malaria transmission is unstable in Pakistan with the highest number of cases reported during the monsoon season. Despite its high incidence, malaria is still a poorly resourced, poorly funded and an uncontrolled disease especially in far-flung areas. Pakistan’s National Malaria Control Program (NMCP), although operational since its inception in 1947, has suffered due to the unstable political, socioeconomic and financial situation prevalent in the country. In Pakistan, more than 300 000 cases of malaria are reported every year with 68% of the cases caused by Plasmodium vivax. It is estimated that about 70–80% of the population accesses the private sector for treatment. As the private sector does not routinely report data to the government, the actual malaria burden could be 4–5 times higher than reported. P. vivax now accounts for more than 85% of all cases requiring hospital admission compared to 54% in 2000. In this review, we have described the saga of poor control of malaria in Pakistan over several years in context of restructuring of the Malaria Control Program, challenges to improvement, and way forward.
Drug resistance, malaria, Malaria Control Program History Received 1 October 2014 Accepted 2 October 2014 Published online 29 October 2014
Introduction
Epidemiology of Malaria in Pakistan
Malaria is a serious global public health problem which contributes significantly in terms of morbidity and mortality. The recent World Malaria Report shows a decline in malaria cases in various African and some Asian countries with effective malaria control programs (MCP) but there was little change in the malaria situation in India, Pakistan and Bangladesh. In Pakistan, more than 80% of the population is at risk, posing immense pressure on economic growth of the region (Donnelly et al., 1997a; Gallup & Sachs, 2001; WHO, 2008). Malaria surveillance and control pose considerable challenges for health care providers in developing countries like Pakistan due to lack of resources, poor infectious diseases control and management. Accessibility of effective affordable diagnostics and emerging drug resistance to mainstay antimalarials are major problems faced by the MCP in Pakistan. The aim of this review is to describe malaria in Pakistan in relation to its changing climatic, social and political backdrop, to describe the current National Malaria Control Program (NMCP) and challenges facing its development and implementation.
Malaria is endemic in Pakistan with low to moderate transmission. Peak incidence appears during July to November coinciding with the rainy season. Heavy monsoon rainfalls and floods annually coupled with poor sanitation, improper management of waste and a poor health care system, mainly in the rural areas, provide a safe haven for the spread of the mosquito vectors of malaria and dengue, thus prevalence of these disease is higher in rural as compared to urban areas. The complex of Anopheles cuilcifacies, An. Stephensi and An. fluvialis are efficient vector for malaria and Aedes aegypti for dengue transmission in south Asia (Sultana & Bhatti, 2001). Reported cases of malaria are increasing each year and the relative frequency of P. falciparum among slide positive malaria cases has increased from 45% in 1995 to 68% in 2006 (Durrani et al., 1997; Hozhabri et al., 2000; Rab et al., 2001). Malaria cases reported from Pakistan represent data from public sector covering only 20% of the population. Due to emergence of insecticide resistant mosquitoes and irrational use and availability of counterfeit antimalarial drugs and growing drug resistance, the exact epidemiology of malaria is difficult to decipher and cannot be stated as being under control. The lack of proper mapping of antimalarial resistance for P. falciparum combined with negligible knowledge of drug resistance in P. vivax may lead to emergence of multidrug resistant malaria. P. vivax and P. falciparum coexist in Pakistan, where P. vivax accounts 68% of the cases (Yasinzai & Kakarsulemankhel, 2009). Figure 1 shows the concentrations
Address for correspondence: N. K. Ghanchi, Section of Microbiology, Department of Pathology and Microbiology, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan. E-mail:
[email protected]. M. A. Beg, Section of Microbiology, Department of Pathology and Microbiology, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan. Tel: +92 21 34864512. E-mail:
[email protected]
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FATA
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KPK
Sindh
Punjab
Azad Jammu Kashmir
Table 1. Coverage of interventions by NMCP in recent years.
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Mean coverage over last 3 years (% population or cases)
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Intervention
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ITN/LLIN
4% of population at risk protected
IRS
20% of population at high-risk protected
IPT ACT delivery for P. falciparum (Case management)
Not adopted 2% of cases
2 1 0 2004
2005
2006
2007
2008
2009
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Figure 1. Annual Parasite Index showing Malaria prevalence in the different provinces of Pakistan (Kakar et al., 2010).
of proportions of P. falciparum Malaria in the different provinces of Pakistan (Kakar et al., 2010). In recent years, several cases of severe life-threatening P. vivax malaria, comparable to falciparum were reported from different regions worldwide (Baird, 2014) thus contesting the benign status of P. vivax. Reports of severe P. vivax cases from Pakistan and neighboring countries force us to rethink the management of P. vivax infections (Beg et al., 2002; Kochar et al., 2005, 2009).
Distribution of malaria in Pakistan Pakistan with 4.5 million malaria cases is categorized as high malaria transmission area in WHO Eastern Mediterranean Region with nearly 100% of the population at-risk (WHO, 2012). In 2011, the total number of confirmed malaria cases in Pakistan (public sector), reported from all the districts were 319 592; including 205 879 (67%) cases due to P. vivax infection and 113 713 (33%) due to P. falciparum infection. It is estimated that about 70–80% of the population goes to private sector for treatment therefore, according to a conservative estimate, the actual malaria burden could be 4–5 times higher (Malaria Control Program of Pakistan, 2014) An increasing trend in Annual Parasite incidence (API) was observed from 1997 to 2000 (0.56); however, this has remained static for the last 5 years (0.82). API data from 2004 to 2009 from MCP reported highest prevalence of P. falciparum in Baluchistan province (Figure 1; Kakar et al., 2010). According to the MCP, API/1000 in Sindh had decreased from 1.12 in 2004 to 0.65 in 2009. Limitations of MCP such as low technical and managerial capacities at the national and provincial level and low coverage (520% of populations) were declared in the report. It was also stated that malaria burden in Sindh may be five times higher than reported due to the above-mentioned limitations (Nizamani, 2006) Malaria is hyper endemic in Punjab and the first case of drug resistance in P. falciparum to chloroquine was reported in 1985 (Fox et al., 1985). In Baluchistan, round the year transmission is observed with rates of P. falciparum among malaria positive slides being high (80–100%) in coastal areas of Baluchistan (Tahir, 2002). The rise in malaria case load and slide positivity rate appears more pronounced for Khyber Pakhtunkhwa (KPK) and Baluchistan than for Punjab and Sindh provinces. Table 1 presents coverage of malaria control
a
Commentsa 2009–2011; ITN and LLIN distributed free-of-cost to population. 2008 (year strategy adopted). No data from subsequent years 2009
Malaria Control Program of Pakistan (http://www.dmc.gov.pk).
interventions by NMCP in recent years. However, relying solely on cases reported by national surveillance system is likely to underestimate the true extent of malaria due to limited availability and accessibility to health facilities particularly in remote areas. Reliable epidemiological data about the distribution of malaria in Pakistan are either sparse or are based on localized surveys undertaken in areas with established health care facilities. The changing climate: political, weather and socioeconomic backdrop Pakistan is a relatively young country. Since its conception in 1947, it has suffered from governmental instability, political and ethnic violence and several (probably global-warming induced) natural disasters. These changing conditions have affected the evolution of malaria and the MCP as well. Afghan refugee crisis and surge of Malaria in the Khyber Pakhtunkhwa region Afghan migration in early 1990s and uncontrolled movement across borders of Afghanistan and Pakistan to date gave rise to a multitude of factors that led to increased malaria prevalence in Khyber Pakhtunkhwa (KPK) previously known as an area of low malaria incidence in the region (Jawaid et al., 2008; Kazmi & Pandit, 2001) The over populated refugee camps with poor living standards in themselves were an ideal breeding ground for the mosquito vector (Kazmi & Pandit, 2001). Basic Health Units in refugee camps were understaffed and underequipped which were major setbacks for the MCP of Pakistan (Suleman, 1988). Kazmi & Pandit (2001) reported that changes in malaria pattern in districts where refugee camps were situated during 1972–1997 confirming that such a large influx of migrants has taken its toll on the health system and the distribution of the disease in the country. However, recent progress in return of the refugees to Afghanistan may relieve the major economic burden but the impact of the changes in epidemiology of malaria in these regions will remain a problem for the health system for many years (Jawaid et al., 2008).
Malaria in Pakistan
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Natural disasters affecting the malaria situation In 2010 and 2011, Pakistan was struck by huge floods due to heavy monsoon rainfall and melting glaciers. According to estimates, 70 of the 136 districts of Pakistan and over 13.8 million people were affected by the floods. Torrential rains and heavy flooding promoted the breeding of Anopheles cuilcifacies and An. fluvialis which resulted in huge outbreaks of malaria in the flood victims. Destruction of health infrastructure, unavailability of care providers and disruption of supply chain of diagnostic aids and medicine resulted in delayed diagnosis and treatment resulting in severe morbidity and mortality particularly in non-malaria-immune individuals, pregnant women and children 55 years of age. According to WHO, a total of 195 000 cases of suspected malaria have been reported from flood affected areas. However, no concrete epidemiological data is available to plan malaria control strategies for future. In order to cope with this catastrophe, 140 net distribution outlets for 800 000 nets, 300 rapid diagnostic centers, 276 malaria microscopy centers, were established. In collaboration with WHO, MCP organized training of 3800 health care providers on malaria diagnosis, treatment and surveillance. Malaria was a leading cause of health seeking behavior in flood affected areas comprised 6% of all consultations (WHO, 2011). Following 2 years of consecutive flooding in Sindh, the number of malaria increased in our tertiary care hospital have risen from 1507 cases/year to 2073 cases in 2012/year (AKU unpublished Data).
The Malaria Control Program Malaria control in Pakistan is complex and has evolved just as malaria control globally has evolved. Sometimes the Pakistan NMCP has not moved with the times despite continuous support from WHO, Global fund and other international funding agencies. During the 1960s, Malaria was almost eradicated in Pakistan due to the nationwide Malaria Eradication Campaign and received widespread success with only 9500 cases reported in 1967, but the program could not be sustained and malaria cases resurged reaching an epidemic proportion in the 1970s. In 1975, the eradication program switched to the MCP with an aim of bringing the malaria burden to manageable levels. In 2011, the NMCP Pakistan has been largely decentralized to the provincial governments, which integrated services for malaria diagnosis and treatment into the general Primary Health Care System. Specialized provincial malaria control departments are responsible for planning activities such as insecticide spraying and for compiling health information. The main tool of the program remains insecticide spraying. According to the reports of MCP the widespread use of insecticides did lower the Annual Parasite Index (API) of the country to a fairly constant level around 1 person per 1000 (Donnelly et al., 1997a,b). In Pakistan, government health services are free, but due to frequent delays in microscopic diagnosis, availability and accessibility of resources, these services remain largely underutilized and used only by the poor. Due to the failure of both the previous programs, Pakistan signed up in 1999 to the Roll Back Malaria initiative. The aim
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of this program was to reduce the burden of malaria by 50% in 2010 and by the year 2015 to have achieved more than 70% of the high risk population have access to effective malaria prevention and treatment facilities. Despite these efforts malaria incidence is still rising. The current Global Fund Round 10 (2009–2014) aims to reduce burden of malaria by 60% in 38 highly endemic districts of Pakistan. The main emphasis is on effective case management, multiple prevention measures, including universal coverage with long lasting insecticide nets (LLINs) and insecticide residual sprays (IRS) and community awareness. In Pakistan there is a need to generate reliable and contemporary information on process, outcome and impact malaria control indicators. The MCP had planned, using Global Fund support, to undertake a baseline malaria indicator survey to provide assessment of progress made in malaria control. Figure 2 describes the evolution of the MCP in Pakistan (Akhtar et al., 2010). Table 1 further delineates the poor coverage of interventions by the MCP in recent years. Use of bed nets, coils, repellent and electric vaporizers are beyond the reach of most, especially in rural areas where incidence of malaria is high but living conditions are poor (DMC, 2013). Vector control techniques and hurdles The major vector species responsible for malaria transmission in Pakistan are Anopheles culicifacies and A. stephensi, although two other species A. superpictus and A. fluviatilis also co-exist as secondary incriminated vectors. Both, A.culicifacies and A. stephensi, considered sensitive to insecticides (DMC, 2013). Sentinel sites have been setup across the country for malaria surveillance and to detect drug resistance and examine the effectiveness of insecticide treated nets (ITNs; Rowland et al., 1996, 1999). Resistance to previously used organochlorides, carbamates and organophosphates has been well documented in many areas of Pakistan (Rowland et al., 1994, 1997) Efforts of the MCP to scale up distribution of long-lasting pyrethroid insecticidetreated nets in high endemic districts did not achieve the desired coverage, as revealed by the 2006–2007 demographic and health survey of Pakistan. The ownership of one insecticide-treated net per household was only 0.8%. Randomized controlled trials regarding the preventive efficacy of Indoor Residual Spraying suggest reduction of P. falciparum infections by 93% and of P. vivax by 79% in northern Pakistan (Pluess et al., 2010; Rowland et al., 2000). Malaria diagnostics in Pakistan According to WHO recommendations malaria diagnosis should be based on parasite detection in all cases (WHO, 2010). Laboratory confirmation of clinical diagnosis of malaria can prevent misdiagnosis or unnecessary treatment due to signs and symptoms, which may overlap with other infections. The majority of malaria in Pakistan is diagnosed by clinical judgment, although blood smear (thick and thin film) microscopy is available in some locations and used to provide confirmed malaria statistics, and RDTs are slowly rolling out through the country. In rural field settings, untrained personnel, unavailability of supplies, poorly maintained microscopes and harsh climatic conditions restrict the
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1998 onward 1947-1960 Healthcare priority as per Bhore Commission Report • Bhore's commission (1943): • Special aenon to malaria • Sind and Punjab provinces idenfied as high-risk for epidemics • Three ered healthcare system • PRESIDENTIAL ORDINANCE IN 1960 TO LAUNCH A PLAN TO ERADICATE MALARIA- Central Malaria Eradicaon Ordinance
1961-1974 Malaria Eradiaon Program • target to eradicate malaria from Pakistan by 1974 • Under aegis of WHO ad USAID • Focus only on rural areas 1960 TO LAUNCH A PLAN TO • Urban areas included in scope in 1975
1974-1997 Malaria Control Program • MEP changed to MALARIA CONTROL PROGRAM • Central Malaria Eradicaon Ordinance repealed by government and malaria control decentraluized in 1977 • Program integrated with Primary health system in1985
Roll Back Malaria to strengthen exisng MCP RBM established by the WHO incollaboraon with UNICEF and UNDP Principle of early diagnosis and prompt treatment Strengthening of peripheral diagnoscs Directorate of malaria Control established MCP now advises a District Level Supervisor for RBM acvity monitoring
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Figure 2. The evolution of NMCP in Pakistan.
use of blood film microscopy and clinicians increasingly prefer non-microscopic method for malaria diagnosis. In South Asia where P. vivax and P. falciparum coexist, large number of mixed infection go undetected and often under-treated leading to severe disease outcomes (Zakeri et al., 2010). Genetic diversity and markers of drug resistance A limited number of studies on genetic diversity and drug resistance have been reported from Pakistan. Genotyping of P. falciparum isolates revel highly polymorphic population with limited multiplicity of infection were found in Pakistan which is in line with reported studies from other low transmission areas (Ghanchi et al., 2010; Khatoon et al., 2010). Ghanchi et al. reported 93% prevalence of pfcrt 76T associated with chloroquine (CQ) resistance and 57% pfmdr1 86Y associated with tolerance to ACTs. The prevalence of sulphadoxine–pyrimethamine resistances associated genes pfdhfr double mutations was 92% and Pfdhps single mutation was observed in 51% of the isolates. These results concur with similar studies reported on relatively small number of patients from northern Pakistan (Ghanchi et al., 2010; Khatoon et al., 2009; Rawasia et al., 2012). A recent study on genetic diversity of P. vivax clinical isolates from southern Pakistan revealed extensively diverse P. vivax populations. Using pvcsp genetic marker, both VK210 and VK 247 types were found with VK210 being the predominant type from southern Pakistan (Raza et al., 2013). Similarly extensive polymorphism and diversity observed in pvcsp and pvmsp1 genetic markers is indicative of natural selective pressure on the parasite for its survival and transmission in the region.
Malaria treatment and rise of drug resistant strains in Pakistan During the late 1970s, Punjab faced an epidemic of malaria, mainly due to the failure of the Malaria eradication program which had resulted in widespread resistance. Drug resistance of P. falciparum to chloroquine in Pakistan was reported first in 1981 in the Sheikhupura district of Punjab and this report was soon confirmed by other such findings all over Pakistan (Fox et al., 1985; Rana & Tanveer, 2004; Robinson et al., 1984). The consolidated analysis of nearly 20 years (1977–1995) of susceptibility studies conducted in the former National Institute of Malaria Research and Training (NIMRT) in
Lahore revealed widespread chloroquine resistance in Pakistan. Owing to ineffective treatment, resistant infections remain patent during the post-transmission season. This may enlarge the ‘‘overwintering’’ parasite reservoir, leading to a surge of new cases when transmission resumes. Other factors potentially contributing to the upsurge in P. falciparum include decreased availability of insecticide for indoor spraying, bed nets and misdiagnosis (Shah et al., 1997). Chloroquine is no longer used for treatment of P. falciparum malaria in Pakistan and currently combination of sulphadoxine + pyrimethamine plus artesunate (SP + AS) is used as first-line treatment for uncomplicated falciparum malaria. Studies conducted in Northern Pakistan assessing efficacy of AS + SP played a key role in defining current treatment policy for uncomplicated falciparum malaria in EMRO region (Kolaczinski et al., 2012; Leslie et al., 2009). According to the MCP most cases of fever and shivering are treated as malaria which has led to irrational use of antimalarial. In far flung areas of Pakistan where health care facilities are not available self-medication is common practice leading to misuse of antimalarial drugs. Pharmaceutical firms sold 70 million courses of antimalarials in 2007. Out of these 27 044 800 courses of chloroquine were used annually makes 38.7% of all antimalarial drug usage in Pakistan, followed by Amodiaquine (30.4%) and sulfadoxine–pyrimethamine (26.9%). The use of Artemether is only 0.9% which helps us to understand the lack of synergy between the government policies and the realities on the ground. ACT was introduced in 2008 in Pakistan and since then 3–6% of physicians were prescribing ACTs for treatment of P. falciparum and reassessing the attitudes of primary care physicians revealed no change in the pattern (Beg et al., 2008; Thaver et al., 2011). For drug resistance, the government has established sentinel sites across the country. The function of these sites is to monitor the efficacy of antimalarial drugs on regular basis. Despite establishment of these sites, no concrete data on clinical in vivo data regarding drug resistance to P. vivax has yet emerged.
Way forward In Pakistan socioeconomic status, access to health care and cultural characteristic also differs between locations
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and populations contributing to the diversity of malaria in this area. Health care facilities should consider health education activities of relevance to malaria as part of the routine services provided to the population. There is an urgent need to strengthen laboratory diagnosis of malaria and ensure availability of adequate and trained staff and drugs at peripheral level targeting both public and private health care centers. Enhancing diagnostics and availability of drugs in public sector will only capture 20% of the population and will not improve overall malaria situation. Since more than 80% population use private sector services therefore more needs to be done to enhance public private partnership Therefore, more needs to be done to improve care through the private sector and provide better access to RDTs and ACT and differential diagnosis of malaria from other febrile illnesses. Promote LLIN availability and awareness among most vulnerable population, i.e. woman and children is much needed. A more proactive regional approach to malaria should be adopted by involving neighboring countries in South Asia to develop a regional network for surveillance and research on malaria. This would help report antimalarial drug resistance efficiently predict endemics or epidemics on a larger scale. Low prescription rate of ATC for P. falciparum reveals lack of communication between policy makers and health care providers. At the same time, continuous evaluation of control program, effective monitoring of drug efficacy and capacity building by strengthening research and training required for long-term outcomes.
Declaration of interest The authors report no declarations of interest.
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