MALARIA: INFECTION BY PARASITES AND ACTION OF ANTIMALARIAL DRUGS IN KHYBER PAKHTUNKHWA, PAKISTAN

Abstract:

Malaria is the disease with the highest death rate and highest spread rate in the whole wide world. The study below is conducted during the widespread of malaria in different northern areas of Pakistan. Surveys were carried out and data was collected quantitatively from specific sites of Malakand Division, Khyber Pakhtunkhwa (K.P.), Pakistan. Certain patients were screened through thick and thin smear films and a Light microscope was used to observe the results. A total number of 2517 of blood samples were tested of which 12% were positive for Plasmodium vivax and Plasmodium falciparum. From both of the strains, P. vivax infected most of the patients and mostly male patients were infected. The proliferation was more during the summer season when there were more mosquitoes and the spread was lowest during the winter season. Also, no mixed infections were detected. To treat these parasitic infections, numerous drugs were produced. The antimalarial drug that treated most of the patients was chloroquine, whereas, some other drugs were also used to treat some patients that had developed some kind of resistance against chloroquine. Plasmodium vivax was the one that was treated using chloroquine as a drug of choice.

Introduction:

Malaria is one of the most lethal infectious diseases all around the world with millions of occurrences every year and a very high death rate, especially in women and children. Under the reported cases of malaria, a report was released in December 2019 which shows that there were approximately 228 malarial cases in the year 2018 and 231 cases in the year 2017 and the death rate was also accordingly higher in 2017. The World Health Organization issued a Global Technical Strategy for malaria 2016-2030 which had a target of lowering the disease by 40% in the year 2020 but there was a continuous rise in the spread of the infection from 2015-2018. The 2020 milestone of WHO is far from achieved with the recent rise of malarial cases in Pakistan. Currently, worldwide the cases of this infection have intensified by 214,217 and 219 million in the years 2015,2016, and 2017. The residents of Pakistan are approximately 180 million and according to the reports, almost 177 million of them are at a chance of infection by the malarial parasite. 3.5 million of them are assumed and approved as infected every year. The list of countries affected by malaria also includes Pakistan. The most common parasitic agent in Pakistan is Plasmodium vivax and after this, Plasmodium falciparum comes next, which had been testified mostly from southern Punjab, Sindh, and Balochistan provinces. Mostly the cases had been reported from the areas near the border of Pakistan with Iran and Afghanistan, where the most dominant species were P. vivax and P. falciparum. The parasitic agents that are mostly known to be causing infection in humans from the plasmodium genus include; P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. Of all the species P. knowlesi is the species that is zoonotic simian which infects rarely. The parasitic agent transfers with the help of a vector which is the female Anopheles mosquito. There are numerous species of Anopheles mosquitos of which almost forty-one species are the major vector species that helps in the transmission of parasitic agent to cause malarial infection. These forty-one species are counted as important malarial vectors.

The humans that are mostly infected by malaria are children up to the age of five years and women that are pregnant. This disease is a life threat for them. The disease can cause critical conditions in humans including renal failure, acute respiratory failure, severe anemia, and different conditions.

The very first drug that was used as an antimalarial drug was Quinine. The source of this drug was a tree. There is also a drug that is utilized as a drug of choice in simple malarial cases for almost half a century, i.e., Chloroquine. This drug is reported to be active against the Plasmodium vivax specie from Pakistan but the parasitic agent had also shown some kind of endurance against this drug. The next most used drug was Artemisinin which acts on the blood, this drug is utilized as a blood schizonticide which simply stops the growth of the parasitic agent at early developmental stages which prevents the uncontrolled condition and the activity of the pathogen's remains at the erythrocyte stage. The current study is conducted to regulate the mode of action and the endurance of parasites against different antimalarial drugs in the residents of Malakand Division, Pakistan.

Materials and Methods:

Selection of Area for study:

The areas selected for the study to be conducted are the two districts of the northwest side of Pakistan, the areas were Swat and Lower Dir of Malakand division, KPK, Pakistan. These areas were selected based on the number of infected individuals.

Design of Study and Collection of Data:

The study was conducted as a questionnaire survey from December 2017 to November 2018. The individuals that partaken in the study had consented beforehand. The data was collected from the nearest diagnostic laboratories, hospitals, and healthcare centers of both districts. The hospitals and healthcare centers were of the government sector and most of the infected patients are treated in these centers. The ethical Committee of the Centre for Biotechnology & Microbiology (C.B.M.), University of Swat, Pakistan confirmed the study.

Selection of Individuals:

The patients selected were from all age groups, and genders with the symptoms and signs of malarial infection. The Individuals that were selected were all from the Malakand division and all other patients were excluded from the study.

The survey form and Clinical Examination:

The data collected from the individuals were detailed in written questionnaire forms before the collection of samples. The survey form covered all the information about the infection and the drugs used for the treatment. The information about the previous history of infection and drugs was included in the questionnaire form.

Collection of Samples:

The samples that were collected were blood from the veins using a sterile syringe from each individual which was instantly transferred to EDTA tubes and labeled accordingly. The samples were further tested in the lab.

Sample Testing:

 The smears of the blood samples were prepared on the slide by taking 2 drops of blood sample on a slide and spreading over it using another slide and air drying. A very thin film of blood was made on the slide which was fixed using ethanol. Also, thick films were made with some samples using a match stick instead of a slide to spread the blood and air dried. The thick films were not fixed with ethanol. The stain used was Giemsa staining to stain both films of the blood sample. The slides were then visualized under the microscope. Different blood cells were seen and the parasite was recognized using 100X magnification of an oil immersion lens. 

Analyzing the Data:

The data produced from the survey forms and the diagnostics examinations were analyzed statistically employing Statistical Package for Social Sciences (SPSS) software version 18 and Microsoft excel program. The frequency of occurrence and the number of infections were analyzed using descriptive statistics.

Results and Discussion:

After conducting this study, the rate of infection in two districts of Malakand division, KP, Pakistan, was very low as the total number of 2517 individuals were tested and only 325 were positive for malarial parasite which was, approximately, only 12.91% and 87.1% were negative results. The species of malaria that was dominant in most patients were P. vivax in almost 99.7% of individuals and only 0.93% of patients were infected by P. falciparum. Both districts were having the occurrence of malarial parasites which higher rate from the Lower Dir district than the swat district.

Mostly the patients who participated in this study were male and there was also a high number of females. The individuals affected most were males. Also, from all of the positive samples, the infection was most likely to occur in the summer season than in winter.

Different antimalarial drugs are used to treat patients. Most patients i.e., 98% were treated with antimalarials successfully. There was also the endurance of the pathogen in only 1.5% of the patients. The treatment success in males was higher i.e., 210 males and only 4 resisted. Whereas in females 110 were treated successfully and only 1 showed resistance. The drug that successfully treated most of the patients was Chloroquine i.e., 311. The other 14 patients are treated using Nivaquine syrup, Artemether, and Artesunate. Only 5 patients showed resistance from all the treated individuals. The response against these drugs was also shown. Chloroquine was most effective after 7h of treatment and some individuals also showed positive results after 48 h of taking the drug, whereas there were also positive results after 24 h of treatment.

The patients that had shown resistance to chloroquine were given another drug to treat the infection. The syrup was given to children to treat the infection. The parasites were also observed under a light microscope in different developmental stages. Both of the species i.e., P. vivax and P. falciparum were observed in different stages of development.

 

Conclusion:

The study above shows that the malarial infection at the Malakand division in Khyber Pakhtunkhwa, Pakistan, is due to these two species of Plasmodium. i.e., P. vivax and P. falciparum. Also, the specie that has dominance was P. vivax in the mostly male population of the district. The P. vivax species was treated using chloroquine drug mostly as a choice of drug in simpler cases but there was also resistance against this drug which was solved by replacing it with other antimalarial drugs. The infection was at a much higher rate in summers than in winters.

References:

·         Zaman, N., Haq, F. U., Khan, Z., Uallah, W., Ualiyeva, D., Waheed, Y., Rizwan, M., Mahmood, R. T., & Mahmood, M. (2022, August 12). Incidence of malarial infection and response to antimalarial drugs at Districts Lower Dir and Swat of Khyber Pakhtunkhwa, Pakistan. Dialogues in Health.

·         Organization, W.H. World malaria report 2018. 2018. Geneva, Switzerland: World Health Organization; 2018

·         Organization WH. World malaria report 2019; 2019.

·         Mohammad J, Rahim F, Ali S. Malaria; causal parasite and clinical features in pediatric patients. J Med Sci. 2014;22(1):39–42.

·         Kakar Q, Khan MA, Bile KM. Malaria control in Pakistan: new tools at hand but challenging epidemiological realities. East Mediterr Health J. 2010;16(Supp):54–60. (2010).

·         Collins WE. Plasmodium knowlesi: a malaria parasite of monkeys and humans. Annu Rev Entomol. 2012;57:107–21.

By: Aqsa Wasim