Epidemiology and Clinical Burden of Malaria in the War-Torn Area, Orakzai Agency in Pakistan

Abstract

Background

Military conflict has been a major challenge in the detection and control of emerging infectious diseases such as malaria. It poses issues associated with enhancing emergence and transmission of infectious diseases by destroying infrastructure and collapsing healthcare systems. The Orakzai agency in Pakistan has witnessed a series of intense violence and destruction. Military conflicts and instability in Afghanistan have resulted in the migration of refugees into the area and possible introduction of many infectious disease epidemics. Due to the ongoing violence and Talibanization, it has been a challenge to conduct an epidemiological study.

Methodology/Principal Findings

All patients were sampled within the transmission season. After a detailed clinical investigation of patients, data were recorded. Baseline venous blood samples were taken for microscopy and nested polymerase chain reaction (nPCR) analysis. Plasmodium species were detected using nested PCR (nPCR) and amplification of the small subunit ribosomal ribonucleic acid (ssrRNA) genes using the primer pairs. We report a clinical assessment of the epidemic situation of malaria caused by Plasmodium vivax (86.5%) and Plasmodium falciparum (11.79%) infections with analysis of complications in patients such as decompensated shock (41%), anemia (8.98%), hypoglycaemia (7.3%), multiple convulsions (6.7%), hyperpyrexia (6.17%), jaundice (5%), and hyperparasitaemia (4.49%).

Conclusions/Significance

This overlooked distribution of P. vivax should be considered by malaria control strategy makers in the world and by the Government of Pakistan. In our study, children were the most susceptible population to malaria infection while they were the least expected to use satisfactory prevention strategies in such a war-torn deprived region. Local health authorities should initiate malaria awareness programs in schools and malaria-related education should be further promoted at the local level reaching out to both children and parents.

Author Summary

The malaria epidemic and endemic in Pakistan is a present and ongoing threat to public health which could have an impact in the nearby regions as well. For the first time, we report a clinical assessment of malaria endemicity in the Orakzai Agency, which is Pakistan’s most neglected area due to Talibanization and war in Afghanistan. Febrile patient blood samples of the area were investigated to report the clinical assessment of malaria caused by Plasmodium vivax and P. falciparum infections. The nested polymerase chain reaction (nPCR) examination detected 154 (86%) and 21 (12%) P. vivax and P. falciparum infections, respectively. We found worsening hygiene conditions in FATA, likely caused by poor socioeconomics and the collapse of the public health infrastructure. Decompensated shock was a common and prominent clinical feature of malaria among all the clinical presentations caused by both P. vivax (53%) and P. falciparum (42.9%). Our results have significant implications for both public health and malaria control in FATA and Pakistan. Our findings illustrate higher prevalence of malaria in children compared to other age groups. Further research on sensible estimates of refugees is required, as well as resistance to anti-malarials.