|Year : 2022 | Volume
| Issue : 4 | Page : 341-347
Epidemiology of Malaria in Kot Kashmir and Serai Gambila (District Lakki Marwat), Khyber Pakhtunkhwa, Pakistan
Muhammad Ashraf Khan
Elementary and Secondary Education Department, Khyber Pakhtunkhwa, Pakistan
|Date of Submission||08-Feb-2022|
|Date of Decision||18-May-2022|
|Date of Acceptance||31-Aug-2022|
|Date of Web Publication||12-Oct-2022|
Muhammad Ashraf Khan
Department of Elementary and Secondary Education, Khyber Pakhtunkhwa, Peshawar
Source of Support: None, Conflict of Interest: None
Background and Objectives: Malaria is one of the serious infections worldwide and is a global major health concern. The preset study aimed to determine the prevalence of malaria in Kot Kashmir (during 2017–2018) and Serai Gambila (in 2015) in the District Lakki Marwat. Methods: The retrospective study was conducted by collecting the data recorded in the official registers and data were consolidated into different age groups and months. Results: Overall Plasmodium vivax accounted for >98% and Plasmodium falciparum <2% of malaria and males showed 56.5% of malaria. August showed the highest prevalence of 20% cases, while February revealed the lowest prevalence of 2.1% cases. Overall males showed higher rates of malaria than females in all the months and all the age groups except equal rates for the month of February in the age group <5 years and May in the age group of 31–45 years, while the age group of 5–14 years showed the highest prevalence of 242 (41.4%) cases, and the age group of 46–60 years demonstrated the lowest prevalence of 24 (4.1%) cases, and patients of ≤30 years contributed to 85.5% of malaria. Age groups of ≤14 years contributed to 78.2% of malaria in Kot Kashmir, while, age groups of 5–30 years demonstrated 75.7% of malaria in Serai Gambila. Conclusions: Overall malaria, as well as vivax malaria in males, steadily increased from April to August followed gradually decreased from the age group of 15–30 years to age group >60 years.
Keywords: Epidemiology, Kot Kashmir, malaria, malaria parasite, Serai Gambila
|How to cite this article:|
Khan MA. Epidemiology of Malaria in Kot Kashmir and Serai Gambila (District Lakki Marwat), Khyber Pakhtunkhwa, Pakistan. J Nat Sci Med 2022;5:341-7
|How to cite this URL:|
Khan MA. Epidemiology of Malaria in Kot Kashmir and Serai Gambila (District Lakki Marwat), Khyber Pakhtunkhwa, Pakistan. J Nat Sci Med [serial online] 2022 [cited 2023 Feb 9];5:341-7. Available from: https://www.jnsmonline.org/text.asp?2022/5/4/341/358410
| Introduction|| |
Guiding strategies and approaches for effective malaria control require knowing the epidemiology of malaria. The epidemiology of malaria transmission demonstrates varying manifestations of malaria infection and malaria illness. Malaria is one of the most common vector-borne parasitic diseases and causes >0.4 million mortality/year globally, mostly (two-third) in children of <5 years of age., It continues to have severe ill effects on human health and livelihoods and is the leading cause of death in many developing countries including Pakistan.,
Global reduction in the incidence of malaria cases occurred by 27% from 2000 to 2015 and by <2% during 2015–2019. In 2018, an estimated 228 million cases of malaria occurred worldwide, which resulted in 405,000 mortalities.,, While approximately 53,216 million were malaria cases globally and a global death toll of about 445,000 was reported in 91 countries in 2016. Malaria remains one of the biggest threats to populations living within the tropical world. The World Health Organization launched a Global Technical Strategy for malaria 2016–2030 in 2015. The strategy sets the target of reducing global malaria incidence and mortality rates by at least 90% by 2030 and contributed to improved access to diagnosis and treatment and developed malaria surveillance.
Malaria is caused by five plasmodia, namely, Plasmodium falciparum, Plasmodium vivax, Plasmodium malaria, Plasmodium ovale, and Plasmodium knowelsi.,,, Both P. vivax and P. falciparum are the most important species due to their widespread prevalence and are the main causes of malaria in Pakistan,, and the country is endemic for both P. vivax and P. falciparum., P. vivax is the dominant species over P. falciparum to cause malaria in Pakistan., P. falciparum is the leading cause of death worldwide from a single infectious agent.,
Malaria is commonly occurring in the provinces of Khyber Pakhtunkhwa (KP), including newly merged districts of former tribal areas, Baluchistan, and Sindh in Pakistan., Mosquitoes such as Anopheles culicifacies and An. stephensi play a major role in spreading malaria in Pakistan,,, and are the most common in Pakistan. Literature on the epidemiology of malaria in the study areas is not available. Therefore, the present studies were conducted to know the epidemiology of malaria in Kot Kashmir and Serai Gambila as well as comparative prevalence of malaria in both localities. Malaria data were obtained from the respective health centers for 1 year for Serai Gambila (2015) and 2 years for Kot Kashmir (2017–2018). The present study contributes to the national malaria control program in Pakistan.
| Methods|| |
Study design/data collection and maintenance
The cross-sectional study includes data collected for 2017 and 2018 from the basic health unit (BHU) of Kot Kashmir and for 2015 from the rural health center (RHC) Serai Gambila official registers of malaria and prepared consolidated reports for each month and year, and maintained a separate record of suspected patients, type of malaria, sex, and age of the patients. Data were classified into six age groups including <5 years, 5–14 years, 15–30 years, 31–45 years, 46–60 years, and >60 years.
Data calculation and statistical analysis
The monthly percentage of total positivity, sex-, and age-wise positivity as well as of P, vivax, and P. falciparum were calculated:
Slide positivity (%) = Total positive slides/total positivity age wise or sex wise × 100
Total collected slides/total positive slides
Pv or Pf positivity (%) = Total positive slides of Pv or Pf × 100
- Total collected positive slides
- Pearson's Chi-squared test (X-squared = 89.6, df = 11, P < 0.0001) is very significant for malaria by months [Table 1]. Pearson's Chi-squared test (X-squared = 107.34, df = 11, P < 0.0001) indicated significant difference for malaria by months [Table 2]. Pearson's Chi-squared test (X-squared = 131.35, df = 11, P < 0.0001) demonstrated significant difference for Malaria by months for polled over data for both stations [Table 3]. Multiple comparisons between months were based on the Benjamini and Hochberg method at P = 0.01 or alpha <0.01.
|Table 1: Monthly prevalence of malaria in Kot Kashmir (Lakki Marwat) during 2017-2018 (data pooled over for both years)|
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|Table 2: Monthly prevalence of malaria in Serai Gambila (Lakki Marwat) in 2015|
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Study sites and population
Kot Kashmir and Serai Gambila
Both the study sites were selected because previous literature on the prevalence of malaria is not available in the study areas. Kot Kashmir is a town as well as the union council of Lakki Marwat. It is located at 32°44'27N and 70°42'50E and has an altitude of 284 m (935 feet), and has a distance of about 13 Km from Serai Gambila. It has a population of 9,903 and has sandy-clayed soil. It has dry and hot weather conditions.
Serai Gambila is located at 32°39'55”N and 70°46'24”E along the river Gambila on the main highway leading from the district Peshawar to the district Karachi at a distance of about 40 km from the district Bannu. It has a population of 2000 and has weather conditions and soil texture similar to Kot Kashmir.
Inclusion and exclusion criteria
The study included gender-wise and age-wise prevalence of malaria as well as type of malaria (vivax and falciparum malaria) sex-wise in the patients who visited the respective health centers in both study localities during their respective period and excluded age-wise prevalence of patients with both types of malaria.
Malaria parasite diagnosis
The suspected patients with symptoms of fever, nausea, chill, and body ache are diagnosed with malaria in the malaria laboratory in the respective health center. Thin and thick smears of the samples (blood) collected from patients are prepared and stained with Giemsa's stain. Thick smears were used to identify malarial parasites and species identification was done on thin smears. In Pakistan, malaria is commonly diagnosed through microscopic examination of blood smears.
| Results|| |
Prevalence of Malaria in Kot Kashmir during 2017–2018 (data pooled over)
Overall, 1650 suspected patients, including 284 cases of malaria with P. vivax have a higher prevalence of 99.3% compared to P. falciparum of 0.7% [Table 1] in Kot Kashmir. Male showed a higher prevalence of malaria (60.6%) than females (39.4%) as well as higher rates of malaria in all months than females. Age groups (<5 years and 5–14 years) contributed collectively to 78.2% of malaria. The disease was highly prevalent from May to August.
Prevalence of malaria in Serai Gambila in 2015
Overall, 1208 suspected patients in Serai Gambila revealed 300 cases of malaria [Table 2], with males showing a higher rate of malaria (52.7%) than females (47.3%). P. vivax contributed to 98.3% of malarial infections. Age groups of 530 years demonstrated 75.7% of malaria. Males showed higher malaria rates than females in all age groups except the age group of 31–45 years. Malaria has comparatively higher rates from August to December with a peak in August and lower rates during January–July.
Comparison of malaria in Kot Kashmir (data pooled over) and Serai Gambila
The malaria data pooled over for both years (2017–2018) of Kot Kashmir [Table 1] and Serai Gambila [Table 2] demonstrated higher malaria prevalence in males (≥52.7%) and a higher prevalence of P. vivax (≥98.3%) than P. falciparum [Table 3]. Higher prevalence of vivax malaria occurred from April through October compared to the remaining months in Kot Kashmir [Table 1], while, Serai Gambila revealed relatively higher prevalence of vivax malaria from June through December [Table 2]. Both males and females patients showed relatively higher prevalence of vivax malaria from May through October in Kot Kashmir [Table 1], while, Serai Gambila revealed higher prevalence of vivax malaria in both genders from August through November [Table 2]. The age group of <5 years in Kot Kashmir and age group of 5–14 years in Serai Gambila were the dominant groups in all age groups. Both stations showed males were dominant over females in all age groups. Malaria showed higher rates from May to October, with peak months (May–August) in Kot Kashmir [Table 1], as well as higher prevalence during August–December, with peak months (August–October) in Serai Gambila [Table 2].
|Table 3: Monthly prevalence of malaria based on data pooled over for both stations of Kot Kashmir (during 2017-2018) and Serai Gambila (2015) in the district Lakki Marwat|
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The overall prevalence of malaria in the study areas
Overall 584 malaria cases were recorded, including 330 (56.5%) were male and 254 (43.5%) were female with P. vivax accounting for 98.8% and P. falciparum (1.2%) during the study [Table 3]. P. vivax accounted for 326 (55.8%) cases in males and 251 (43%) cases in females [Table 3] and [Figure 1]. The age group of 5–14 years demonstrated the highest rate of malaria with 242 (41.4%) cases, followed by the age group of 15–30 years with 138 (23.6%), age group of <5 years with 119 (20.4%), age group of 3145 years with 60 (10.3%), age group of 46–60 years with 24 (4.1%), and age group of >60 years with 1 (0.2%) positive case [Table 3] and [Figure 1].
|Figure 1: Sex-wise and age-wise percentage of malaria based on aggregate data for both stations including Kot Kashmir (2017–2018) and Serai Gambila (2015)|
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Data pooled over both stations for the study period indicated the highest malaria prevalence in August (20%), followed by September (14.6%), October (13.9%), July (12.5%), June (9.3%), May (8.9%), and November (6%), while the lowest (2.1%) was recorded in February [Table 3] and [Figure 2]. The rate of vivax malaria gradually increased [Table 3] and [Figure 2] from early spring (March) and reached to peak in summer (August), and followed by a gradual decrease from late summer (September) to early winter (December). A relatively lower prevalence of malaria was recorded [Table 3] and [Figure 2] in the winter (January and February) and the early spring (March). Vivax malaria has a higher prevalence in males than females in all months except in July [Table 3] and [Figure 3]. Overall few cases of P. falciparum were found in June, August, November, and December, while a few mixed cases of P. vivax and P. falciparum were also recorded in August and October during the study [Table 3] and [Figure 1].
|Figure 2: Monthly percentage of malaria based on aggregate data for both stations including Kot Kashmir (2017–2018) and Serai Gambila (2015)|
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|Figure 3: Monthly percentage of Plasmodium vivax distribution in males and females based on aggregate data for Kot Kashmir (2017–2018) and Serai Gambila (2015)|
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| Discussion|| |
Mosquito-borne diseases are responsible for substantial mortality and morbidity worldwide. The present study showed similarities and variations in the prevalence of malaria both in Kot Kashmir and Serai Gambila. Nevertheless, both stations revealed that P. vivax was the dominant species with ≥98.3% of malarial infections [Table 1] and [Table 2] because of (1) there seems to be no second exothermic cycle and true relapses do not occur in P. falciparum, whereas in P. vivax relapses are present, (2) the longevity of P. falciparum in man seldom exceeds 1 year and P. vivax usually die-out within 3 years. The higher prevalence of P. vivax in the study areas is supported by Karim et al. who concluded that P. vivax is a major contributor to the spread of malaria in tribal districts of the KP. Overall males showed a higher prevalence of malaria (56.5%) than females in the study areas [Table 3] because males are more exposed/susceptible to the anopheles mosquitoes.
The combined data of age groups (<5 yrs and 5-14 yrs) in Kot Kashmir showed 78.2% malaria [Table 1], while pooled data of age groups (5-14 yrs and 15-30 yrs) indicated 75.7% prevalence of malaria in Serai Gambila [Table 2]. The children of age ≤14 years contributed 78.2% and 46.3% of the overall malaria infection in Kot Kashmir and Serai Gambila, respectively [[Table 1] and [Table 2], respectively]. Overall, the disease showed a higher prevalence of malaria (85.5%) in the aged ≤30 years [Table 3]. Thus, children as well as people of age ≤30 years are more vulnerable/expose to malaria. Karim et al. investigated and found young males are largely affected by malaria in tribal districts of the KP province. Male showed higher rates of malaria than females in different age groups in both stations. Variations in monthly/seasonal patterns of malaria exist between the two localities: The disease was highly prevalent from early summer to late summer with a peak in July in Kot Kashmir [Table 1], and from mid-summer through late autumn with a peak in August in Serai Gambila [Table 2]: Rainfall occurs during July–August in the study sites contribute to the higher peaks in malaria during these months. The transmission of malaria occurred throughout the year, but more cases were reported from July to November after the rains.,
Vivax malaria highly prevailed from May to October in both males and females [Table 3]. Malaria transmission is considered to be unstable, with major P. vivax transmission peaking from June to September and again from April to June when relapses of infections acquired the previous season are observed., P. falciparum malaria prevailed during June–December [Table 3] and is supported by Bouma et al. and Khattak et al. who described the major transmission period for P. falciparum in Pakistan as between August and December. Although the majority of malaria cases in Pakistan are caused by P. vivax, trends in the past few decades have indicated that P. falciparum infection is on the rise.
The present study was supported by Ajakaye and Ibukunoluwa who reported a higher prevalence of malaria in males (58.5%) than in females (53.2%) in Nigeria. Ahmad et al. found 64.4% were male and 35.6% were female patients of malaria, and recorded the highest number of patients (76.71%) in the age groups of 15–64 years, and further recorded a higher prevalence of P. vivax (98.6%) than P. falciparum (1.4%) in Lal Qilla (KP) in 2002. The present study reported malaria highly prevalent from May to October, with a peak in August (20%) and recorded the lowest rate of malaria in February (2.1%). However, Ahmad et al. found the highest prevalence of malaria (32.89%) in October, while the lowest (2.63%) was recorded in June.
Khan investigated malaria patients admitted to combined military hospital Bannu during 2010–2011 and found that 90% had P. vivax infection, while 7% of patients were infected with P. falciparum and 3.0% of the patients have mixed infections of both species. P. vivax was common during August–October, with a peak in October (20%), whereas P. falciparum infection was the most common during October–December, with a peak in October.
Khan et al. recorded the prevalence of P. vivax malaria (91.5%), P. falciparum malaria (7.5%), and mixed infections of both P. vivax and P. falciparum (1%) during 2012–2013 in Bannu. They found males (50.11%) and females (49.89%) were infected with malaria and reported P. vivax contributed to >90% of the total malarial infection both in males and females. Further, they also recorded both male and female children of the age group of 5–14 years were the most affected with vivax malaria. Khan et al. found P. vivax (83.4%), P. falciparum (16.6%), and mixed infection of 5.4% in 2011 in Bannu and the age groups of ≤10 years and 11–20 years showed the highest malaria in males (32.2%) and females (28.1%), respectively.
Khattak et al. observed that 18% were P. falciparum, 76% were P. vivax, and 6% were mixed cases of both species. Shah et al. found malaria patients with P. vivax (76.2%) and P. falciparum (23.8%) in district Dir Lower with males showed a higher prevalence of 62% and the age group of 21–30 years showed the highest prevalence of both species. While P. vivax was most prevalent in October and the prevalence of malaria was highest in October and lowest in January.
Majid et al. described the male malaria patients to female malaria patients ratio as 43.7% and 56.3%, respectively, in District Mardan. They found P. vivax and P. falciparum accounted for 92.6% and 7.4% of malaria prevalence, respectively, and the age group of 0–20 years was dominant, representing 47.4% of malarial cases. Further, they also recorded the highest malaria prevalence of 12%, and the lowest prevalence of 3.83% in October and January, respectively, with females, infected more as compared to males.
Khan et al. described higher prevalence of malaria (54.74%) in male patients than in females (45.26%), and overall 94.16% patients were infected with P. vivax and 5.84% were infected with P. falciparum in District Kohat. The age group of 11–20 years represented the highest rate of malaria (35.77%), and the least prevalence (2.19%) was found in the age group of ≥51 years. We should focus on the control of highly infectious diseases such as malaria, pneumonia, and diarrhea which are a major health threat globally and are leading causes of mortality in children <5 years of age.
| Conclusions|| |
P. vivax contributed to >98%, while P. falciparum accounted for <2% of malaria in Kot Kashmir and Serai Gambila. Both stations demonstrated a higher malaria rate in males (>52%) than females (<48), as well as overall males, showed higher or equal rates of malaria than females in all age groups as well as all months. Age groups <5 and 5–14 years contributed to 78.2% of malaria in Kot Kashmir, and the age range from 5 to 30 years led to 75.7% of malaria in Serai Gambila. Overall data pooled over for both stations indicated 85.5% of malaria in the age ≤30 years. Malaria was most noticeably prevalent from May to October, with a peak in August (20%) and the lowest rate in February (2.1%).
Children as well as people of age ≤30 years need more protection from mosquitoes. In addition, mosquitoes control efforts should be continued from early spring (1st week of March) until the end of autumn in the study areas.
Ethics approval and consent to participate
The medical officers of BHU Kot Kashmir and RHC Serai Gambila (Lakki Marwat) granted ethical approval for this study with reference No. 313030, dated January 23, 2020. I willingly participated in the research.
Limitation of the study
This study is limited as not determined types of malaria based on different age groups.
The medical officers of BHU Kot Kashmir and RHC Serai Gambila (Lakki Marwat) are acknowledged for granted ethical approval to the present study. I am grateful to Mr. Anwar Khan, malaria control supervisor and who is also working as a microscopist, and Mr. Tayyab, laboratory technician in the BHU of Kot Kashmir, for providing me with the monthly record of malaria for both stations. Jos Feys senior research fellow at KU Leuven University (Belgium) is highly thanked for his help in the statistical analysis of the data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]