Current situation and challenges in implementing Malaria control strategies in Pakistan

A Community-Based Survey on Health-Care Utilization for Pneumonia in Children in Peri-Urban Slums of Karachi, Pakistan

Pneumonia, as defined by WHO, is a syndromic diagnosis characterized by presence of cough or difficult breathing. Presentation to health-care provider depends on timely identification of signs and symptoms by caretakers. We explored patterns of health-care utilization among caretakers of a randomly selected sample of 1,152 children aged 2-59 months, residing in low-income settlements of Karachi, Pakistan. Information on household demographics, occurrence of pneumonia-specific symptoms, care seeking, air quality, and knowledge regarding preventive measures for pneumonia was collected. Predictors of care seeking were estimated using weighted logistic regression. Prevalence of pneumonia with cough and rapid or difficulty in breathing was found to be 40.8% and 37.1% in infants (2-11 months) and children (12-59 months), respectively. Ninety-five percentage of caretakers sought care, 68.5% privately. Odds ratios (ORs) for independent predictors of care-seeking were as follows: younger age of child (infants compared with children), 3.60 (95% CI = 2.65-4.87); caretaker with primary education compared with none, 3.40 (2.46-4.70); vaccine awareness, 1.65 (1.45-1.87); and breastfeeding awareness, 1.32 (1.13-1.53). Presence of symptoms such as fever OR, 1.51 (1.30-1.76); tachypnea, 1.57 (1.35-1.83); chest indrawing, 2.56 (2.05-3.18); persistent vomiting, 1.69 (1.37-2.09); and recurrent illness, 2.57 (2.23-2.97) were also predictive. There is high health-care utilization for pneumonia with the skewed presentation toward private services. Strategies should be focused on making pneumonia care standardized, efficient and affordable, especially in the private sector.

Elucidation of Malaria on Metabolic Activities During Pregnancy

Background:

Malaria is extended to more than 90 countries of the world, and is also considered as a major public health and socio-economical problem.

Objective:

The aim of this study is the elucidation of malaria on metabolic activities in pregnancy.

Material and Methods:

A total of 60 patients with gestational vivax malaria were recruited in this study, and 60 healthy pregnant women were selected as a control group. These women were selected using simple random sampling technique. A sample of 5 ml venous blood was drawn from each patient, centrifuged at 5000 rpm for 20 minutes to separate the serum. The serum samples were analyzed for enzyme activity such as Alkaline Phosphatase (ALP), Creatine Phospho Kinase (CPK), Lactate Dehydrogenase (LDH), and Serum Glutamic Oxaloacetic Transaminase / aspartate aminotransferase (SGOT/AST) by using kit method on Microlab 300 and trace metal content Magnesium, Iron, Copper and Zinc (Mg, Fe, Cu, and Zn) by Atomic Absorption Spectroscopy (Varian AAS Model A-20).

Results:

There was an increased level of Alkaline Phosphatase (ALP), Creatine Phospho Kinase (CPK), Lactate Dehydrogenase (LDH), and Serum Glutamic Oxaloacetic Transaminase / aspartate aminotransferase in sixty pregnant women suffering from vivax malaria as compared to the control subjects. Whereas, the low concentrations of serum iron, copper, magnesium and zinc were observed in patients as compared to the control subjects.

Conclusion:

The findings of this study suggest that in order to enhance the immunity and develop resistance towards malaria during pregnancy, it is necessary to balance enzyme activity and provide diverse metals in the therapy to cure this disease.

Distribution of Mutations Associated with Antifolate and Chloroquine Resistance among Imported Plasmodium vivax in the State of Qatar

Plasmodium vivax is the most prevalent parasite worldwide, escalating by spread of drug resistance. Currently, in Qatar, chloroquine (CQ) plus primaquine are recommended for the treatment of P. vivax malaria. The present study examined the prevalence of mutations in dihydrofolate reductase (dhfr), dihydropteroate synthase (dhps) genes and CQ resistance transporter (crt-o) genes, associated with sulphadoxine-pyrimethamine (SP) and chloroquine resistance, among imported P. vivax cases in Qatar. Blood samples were collected from patients positive for P. vivax and seeking medical treatment at Hamad General Hospital, Doha, during 2013-2016. The Sanger sequencing method was performed to examine the single nucleotide polymorphisms in Pvdhfr, Pvdhps, and Pvcrt-o genes. Of 314 examined P. vivax isolates, 247 (78.7%), 294 (93.6%) and 261 (83.1%) were successfully amplified and sequenced for Pvdhfr, Pvdhps, and Pvcrt-o, respectively. Overall, 53.8% (N = 133) carried mutant alleles (58R/117N) in Pvdhfr, whereas 77.2% (N = 227) and 90% (N = 235) isolates possessed wild type allele in Pvdhps and Pvcrt-o genes, respectively. In addition, a total of eleven distinct haplotypes were detected in Pvdhfr/Pvdhps genes. Interestingly, K10 insertion in the Pvcrt-o gene was observed only in patients originating from the Indian subcontinent. The results suggested that CQ remains an acceptable treatment regimen but further clinical data are required to assess the effectiveness of CQ and SP in Qatar to support the current national treatment guidelines. In addition, limited distribution of genetic polymorphisms associated with CQ and SP resistance observed in imported P. vivax infections, necessitates regular monitoring of drug resistant P. vivax malaria in Qatar.

An assessment of national surveillance systems for malaria elimination in the Asia Pacific

Background

Heads of Government from Asia and the Pacific have committed to a malaria-free region by 2030. In 2015, the total number of confirmed cases reported to the World Health Organization by 22 Asia Pacific countries was 2,461,025. However, this was likely a gross underestimate due in part to incidence data not being available from the wide variety of known sources. There is a recognized need for an accurate picture of malaria over time and space to support the goal of elimination. A survey was conducted to gain a deeper understanding of the collection of malaria incidence data for surveillance by National Malaria Control Programmes in 22 countries identified by the Asia Pacific Leaders Malaria Alliance.

Methods

In 2015–2016, a short questionnaire on malaria surveillance was distributed to 22 country National Malaria Control Programmes (NMCP) in the Asia Pacific. It collected country-specific information about the extent of inclusion of the range of possible sources of malaria incidence data and the role of the private sector in malaria treatment. The findings were used to produce recommendations for the regional heads of government on improving malaria surveillance to inform regional efforts towards malaria elimination.

Results

A survey response was received from all 22 target countries. Most of the malaria incidence data collected by NMCPs originated from government health facilities, while many did not collect comprehensive data from mobile and migrant populations, the private sector or the military. All data from village health workers were included by 10/20 countries and some by 5/20. Other sources of data included by some countries were plantations, police and other security forces, sentinel surveillance sites, research or academic institutions, private laboratories and other government ministries. Malaria was treated in private health facilities in 19/21 countries, while anti-malarials were available in private pharmacies in 16/21 and private shops in 6/21. Most countries use primarily paper-based reporting.

Conclusions

Most collected malaria incidence data in the Asia Pacific is from government health facilities while data from a wide variety of other known sources are often not included in national surveillance databases. In particular, there needs to be a concerted regional effort to support inclusion of data on mobile and migrant populations and the private sector. There should also be an emphasis on electronic reporting and data harmonization across organizations. This will provide a more accurate and up to date picture of the true burden and distribution of malaria and will be of great assistance in helping realize the goal of malaria elimination in the Asia Pacific by 2030.

Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: systematic review and meta-analysis

BACKGROUND

Anemia is a leading cause of maternal deaths and adverse pregnancy outcomes in developing countries.

OBJECTIVES

We conducted a systematic review and meta-analysis to estimate the pooled prevalence of anemia, the association between maternal anemia and pregnancy outcomes, and the population-attributable fraction (PAF) of these outcomes that are due to anemia in low- and middle-income countries.

DESIGN

PubMed, EMBASE, CINAHL, and the British Nursing Index were searched from inception to May 2015 to identify cohort studies of the association between maternal anemia and pregnancy outcomes. The anemic group was defined as having hemoglobin concentrations <10 or <11 g/dL or hematocrit values <33% or <34% depending on the study. A metaregression and stratified analysis were performed to assess the effects of study and participant characteristics on adverse pregnancy risk. The pooled prevalence of anemia in pregnant women by region and country-income category was calculated with the use of a random-effects meta-analysis.

RESULTS

Of 8182 articles reviewed, 29 studies were included in the systematic review, and 26 studies were included in the meta-analysis. Overall, 42.7% (95% CI: 37.0%, 48.4%) of women experienced anemia during pregnancy in low- and middle-income countries. There were significantly higher risks of low birth weight (RR: 1.31; 95% CI: 1.13, 1.51), preterm birth (RR: 1.63; 95% CI: 1.33, 2.01), perinatal mortality (RR: 1.51; 95% CI: 1.30, 1.76), and neonatal mortality (RR: 2.72; 95% CI: 1.19, 6.25) in pregnant women with anemia. South Asian, African, and low-income countries had a higher pooled anemia prevalence than did other Asian and upper-middle-income countries. Overall, in low- and middle-income countries, 12% of low birth weight, 19% of preterm births, and 18% of perinatal mortality were attributable to maternal anemia. The proportion of adverse pregnancy outcomes attributable to anemia was higher in low-income countries and in the South Asian region.

CONCLUSION

Maternal anemia remains a significant health problem in low- and middle-income countries.