978-3-659-88187-9

DEDICATION This thesis is especially dedicated to my Parents,

Brothers, Sister, Friends and Teachers for Unfail help, Courage and Strong Support.

ACKNOWLEDGMENT

List of Figures

List of Tables

Abstract

Chapter 1

1 Introduction and review of Literature

1.1 Malaria Background

1.2 Mosquito

1.3 Plasmodium

1.3.1 Plasmodium falciparum

1.3.2 Plasmodium vivax

1.3.3 Plasmodium malariae

1.3.4 Plasmodium ovale

1.3.5 Plasmodium knowlesi

1.4 Mode of Transmission of the Parasite

1.5 Pathogenesis

1.6 Sign and Symptom of Malaria

1.6.1 Clinical Symptoms

1.7 Diagnosis

1.7.1 Serological tests

1.8 Treatment of Malaria

1.8.1 Artemisinin (Qingnasou)

1.8.2 Chloroquinine

1.8.3 Halofantrine

1.8.4 Mefloquine

1.8.4 Primaquine

1.8.5 Fansidar (pyrimethamine + sulfadoxine)

1.8.6 Quinine

1.9 Immunity to Malaria

1.9.1 Innate immunity

1.9.2 Acquired immunity

1.10 Epidemiology

1.11 Malaria in Pakistan

Rationale of study

Objective

Chapter 2

2 Materials and Methods

2.1 Study area

2.2 Study design

2.3 Data Collection

2.5 Sample collection procedure

2.6 Microscopy

2.7 Prevalence rate

2.8 Descriptive analysis

2.9 Statistical analysis and graphical Representation

2.10 Ethical Approval

Chapter 3

3 Results

3.1 Differential Prevalence

3.2 Age Wise Prevalence

3.4 Descriptive wise Prevalence

3.5 Tehsil Wise Prevalence

3.6 Month Wise Prevalence

3.7 Statistical Analysis

Chapter 4

4 Discussion

Conclusions

Recommendation

Chapter 5

5 References

ACKNOWLEDGMENTS

All praises to Allah, Lord of all the worlds. The most Affectionate, The most Merciful. Master of the day of Requital. We worship You alone, and beg You alone for help. Guide us in the straight path. The path of those whom You have favored. Not those who have earned Your anger and nor of those who have gone astray. Thousands salutations and

Muhammad (P.B.U.H) and blessing of Allah may upon his companions and friends of Allah.

Foremost, I would like to express my heartfelt to my supervisor, Dr. Malik Mujaddad Ur Rehman Ex-Assistant Professor, Department of Microbiology, Hazara University, Mansehra, who shared with me a lot of his expertise and research insight. Through my research-writing period, he encourages me during the hard time of research work and makes available all his expertise during my research work. His pleasant attitude will be everlasting to me. I always pray for his long life and health in future.

I offer my cordial and profound thanks to Dr. Isfahan Tuaseef, HOD, Department of Microbiology, Hazara University, Mansehra, for his constructive criticism, unfailing help and valuable suggestion throughout my studies.

I cannot finish without saying how grateful I am to my family and friends. I wish to thank my dear parents, Brothers Mr. Muhammad Usman, Mr. Muhammad Iqbal, Abdus Salam and Abdul Basit and my friends Mr. Junaid Ali Shah, Mr. Tahir Ali Khan, Mr. Tauseef Ahmad, Mr. Zakir Ullah, Mr. Imran Aman and Mr. Imran Zamen (M.Phil Research Scholars). They have always supported and encouraged me to do my best in all matters of my life.

To those who indirectly contributed in this research work, your kindness means a lot to me. Thank you very much.

Mr. Abdul Majid

List of Abbreviation

BHU Basic Health Unit

bp Base pair

CDC Central Disease Control

CS Cirbro Spinal

ELISA Enzyme Linked immune sorbent assay

IFA Immunofluorescent-Antibody

IRIN Integrated Regional Information Networks

NHP Non-Human Primates

PCR Polymerase Chain Reaction

Pf P. falciparum,

Pm P. malariae

Pv P. vivax

Rrna Ribosomal RNA

WHO World Health Organization

List of Figures

S. No. Figures Name Page No.

1 Malarial Mosquito 2

2 Life cycle of Plasmodium (www.cdc.gov.com) 7

3 Study area of district Mardan/Data collection centre 19

4 Flow chart malarial infection in district Mardan 23

5 Differential prevalence rate 25

6 Age Group wise distribution of malarial infection 27

7 Descriptive wise and differential wise prevalence of malaria 29

8 Tehsil wise prevalence rate in district Mardan 29

9 Descriptive, Monthly and Differential wise prevalence of malaria 30

List of Table

S. No. Table Name Page No.

1 Descriptive statistics of malaria in district Mardan 24

2 Descriptive statistics 24

Differential prevalence of malaria Plasmodium of district Mardan 25

4 Age wise frequency of malria positive cases 26

5 Gender wise and species wise distribution of the positive malarial patients

27

6 Distribution of positive cases on the bases tahsil wise 28

7 Month wise incidence of malaria cases gender wise or differential wise. 29

8 Statistical analysis of species wise distribution on gender wise through chi square test

30

9 Statistical analysis of age wise distribution through chi Square test 30

10 Statistical Analysis of tehsil wise distribution through chi Square test 30

10 Statistical analysis of month wise distribution through chi square test 31

Abstract

The epidemiological survey and information of malaria is crucial for designing the drugs and vaccines on the basis of result and findings. A cross-sectional study was conducted in the district Mardan, KP from 1st January to 31st December, 2013. For statistical analysis PHstate2 version 2.5 was used. The P-value below 0.05 was considered significant. Total 11272 malarial suspected patients was investigated, in which 766 (7.79%) were seen positive in which 335 (2.96 %) male and female, 431 (3.83 %) were found infected with malaria infection the differential prevalence the P. vivax were most reported 709 (92.56%) were the highest frequency followed by P. falciparum 57 (7.44%). Age wise highest number of cases 363 (47.4%) in age group 1: 0-20 years followed by 283 (36.94%) age group 21-40. Female were more susceptible to malarial infection 431 (3.83%) infected cases in which 400 (92.8%) were P. vivax and 31 (7.14%) were P. falciparum. Prevalence rate was found high in tehsil Mardan 366 (3.25%) followed by tehsil Taht Bhai 305 (2.7%) and tehsil Kattlang 95 (0.84%). The highest prevalence was recorded in the month of October, November and September. From our study it was concluded that the general predominance was discovered moderate. The illness proportion was revealed high among the female where age insightful dispersion was advised high in age between age group 0-21 years. P. vivax is the regular specie and high proportion of malaria infection was accounted for in district Mardan.

Chapter 1

1 Introduction and review of Literature

1.1 Malaria Background

Malaria is an infectious disease transmitted into humans by the bite of female infected mosquitoes of the Anopheles genus and a mosquito-borne infectious disease of humans and other animals spp. caused by parasitic protozoans belong to the genus Plasmodium(phylum Apicomplexa) (Nayyar et al., 2012). In humans, malaria is caused by five species of Plasmodium which includes P. falciparum, P. malariae, P. ovale, P. vivax and P. knowlesi (Collins, 2012). Malaria is most likely the second infectious disease, after tuberculosis, of morbidity and mortality all over the world. It has been approximate that 300-500 new medical cases of malaria (more than 90% of which in tropical Africa) occur every year worldwide, causing 1.5 to 2.7 million deaths, In the age-group 1-4 years, malaria is the cause of nearly one-quarter of all deaths in some African Countries. Outside Africa, other Countries pay a heavy tribute to malaria (WHO, 2014). The great majority being recorded in African children among them India, Brazil, Sri Lanka and Afghanistan are the most involved. Among those infected, P. falciparum is the most common species identified approximately (75%) followed by P. vivax (20%), although P. falciparum traditionally accounts for the majority of deaths (Nadjm and Behrens, 2012). Commonly, the disease is transmitted by a bite from an infected female Anopheles mosquito, which introduces the organisms from its saliva into a person's circulatory system. In the blood, the parasites travel to the liver to mature and reproduce (Nayyar et al., 2012).

1.2 Mosquito

Mosquitoes are a gathering of little, midge like flies: the Culicidae. Though a few creature mixed bags are protected or even important to mankind, the females of most species are ectoparasites whose tube-like mouthparts enter the skin to suck the blood. An immense number of creature gatherings feast upon the blood of distinctive sorts of hosts, overwhelmingly vertebrates, including warm blooded animals, winged creatures, reptiles, animals of area and water, and even a couple sorts of fish. In going from host to host, some transmit amazingly destructive malarial infection s, for example, malaria, yellow fever, west Nile infection and filariasis (Brown, 1993).

1.3 Plasmodium

Plasmodium is a unicellular parasite, responsible for causing malarial infection. It has more than 100 species, produce malaria in flying creatures, creatures and people, and so on. The malaria parasite exhibits a complex life cycle involving an insect vector (mosquito) and a vertebrate host (human). Five Plasmodium species infect humans: P. falciparum, P. vivax, P. ovale, P. knowlesi and P. malariae. All five species show a comparable life cycle with just minor varieties (Collins, 2012).

1.3.1 Plasmodium falciparum

Plasmodium falciparum is a protozoan parasite, one of the types of Plasmodium that cause malaria in people. It is transmitted by the female Anopheles mosquito. Malarial fever brought on by this species or falciparum intestinal affliction is the most risky sort of intestinal ailment (Perlmann et al., 2000), with the most noteworthy rates of complexities and mortality. As of the latest World Health Organization report in 2014, there were 198 million occurrences of malarial fever worldwide in 2013, with a normal going of 584,000. Basically every malarial passing is achieved by P. falciparum (WHO, 2014).

1.3.2 Plasmodium vivax

Plasmodium vivax is a protozoal parasite and a human pathogen. The most normal and for the most part passed on explanation behind rehashing (Amiable tertian) malarial fever, P. vivax is one of the five sorts of Malarial fever parasites that normally taint people (White, 2008). It is less destructive than Plasmodium falciparum, the deadliest of the five, however vivax malarial fever can prompt extreme illness and demise because of splenomegaly (a pathologically developed spleen) (Anstey et al., 2008).

1.3.3 Plasmodium malariae

Plasmodium malariae is a malaria parasite that causes an illness that has been perceived following the Greek and Roman human advancements more than 2,000 years back. Quartan, tertian, and semi tertian examples of fever in patients were depicted by the early Greeks. After the revelation by Alphonse Laveran in 1880 (Laveran, 1980) that the causative agent for malaria was a parasite, detailed studies on these organisms commenced. The early point by point work of Golgi in 1886 showed that in a few patients there was a relationship between the 72-hour life cycle of improvement of the parasites and a comparative periodicity of the paroxysm (chill and fever design in the patient), though in different patients there were 48-hour cycles of advancement (Golgi, 1986). He came to the conclusion that there must be more than one species of malaria parasite responsible for these different patterns of cyclical infection.

1.3.4 Plasmodium ovale

Plasmodium ovale is types of parasitic protozoa that cause tertian malaria in people. It is one of a few types of Plasmodium parasites that taint people including P. falciparumand Plasmodium vivax which are in charge of most malarial disease. It is uncommon contrasted with these two parasites, and significantly less perilous than P. falciparum and P. ovale has as of late been indicated by hereditary systems to comprise of two subspecies, P. ovale curtisi and P. ovale wallikeri (Sutherland et al., 2010).

1.3.5 Plasmodium knowlesi

Up to this point just four sorts of (Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae and Plasmodium ovale) were known not malaria in people. On the other hand, a fifth species, Plasmodium knowlesi, has been recognized as a reason for human malaria in all nations in Southeast Asia (Singh and Daneshvar, 2013), and extending to the Andaman Islands and Nicobar in India (Tyagi et al., 2013). In Malaysian Borneo, P. knowlesi is the main cause of admissions for malaria in certain hospitals, including Sarikei Hospital, and can lead to fatal infections (Rajahram et al.,2012).

1.4 Mode of Transmission of the Parasite

The advancement of human Plasmodia begins with sporozoites being infused into the circulatory system after the man is nibbled by tainted female mosquito (Phillips, 1983). The parasite has three main phases. These are: Liver phase, Blood phase and Mosquito phase (Phillips, 1983; Knell, 1991, America Public Health Association (APHA, 1995; Palsson 1999). The sporozoites are injected by the mosquito into the human beings and they enter the liver. This procedure can happen inside of 30 minutes after the parasite (the sporozoites) was being infused into human blood. In the liver cells, the sporozoites develop into tissue schizont and they undergo asexual division. This is called schizogony or merogony, and the parasites are called meronts (Knell 1991, APHA 1995). A great many merozoites, contingent on every individual species, are delivered in each meront. In the case of P. falciparum and P. malariae, the development of all parasites in the liver takes place at about the same time. However, in the case of P. vivax and P. ovale a portion of the parasites change into hypnozoites. At the point when different parasites build up, the hypnozoites lie torpid in the liver cells to create months or years after the fact and reasons the ailment to breakout (Knell, 1991; APHA, 1995).

The hypnozoites start to develop later after the same sexual multiplication as the sporozoites that don't get to be hypnozoites. Six to fourteen days after disease, contingent on the species, the merozoites leave the tissue and enter the blood where they attack the blood cells. The period from the infection until the first appearance of the merozoites in erythrocytes is called prepatent period and it is short for P. falciparumand long for P. malariae (Knell, 1991; APHA, 1995; Palsson, 1999).

After the merozoites attacked the red platelets, they get to be erythrocytic trophozoites and developed schizont. At last they develop and separate into 8-16 new merozoites relying on every types of the parasite. This procedure is known as blood schizogony. The procedure of schizogony in the blood proceeds at customary interims. On account of P. falciparum, P. vivax and P. ovale, it happens at regular intervals (tertian) and on account of P. malariae, it occurs every 72 hours. This is a rehashed procedure until the expanding parasitaemia is possessed by invulnerability or by chemotherapy. This abiogenetic advancement of the parasite is connected with the clinical manifestation of the sickness. As the illness advances a few merozoites form into male (smaller scale)

and female (large scale) gametocytes. In the event that they are exchanged to another mosquito, they further form into sporozoites and can be transmitted to someone else (Knell 1991; APHA, 1995; Palsson, 1999).

1.5 Pathogenesis

The life cycle of the malaria parasite is mind boggling. The malarial infection starts when a mosquito bolsters on a human host's blood. Contact from the mosquito salivary organs causes an intravenous vaccination of sporozoites; the protozoan cells which are contaminate new has. They are immediately transported to hepatocytes, the lion's share constituent of the liver. They hatch and duplicate in the liver for a middle of eleven days (Trampuz et al., 2003), and soon thereafter the following period of the parasite's life cycle, an agamic merozoites or little cell, bursts the host's hepatocytes (liver cells) and enters the circulation system. The merozoites attack erythrocytes (red platelets), where they start the pathogenic period of the ailment. Amid this stage, they are suggested to high thickness in the host's blood (Miller et al., 1994).

Amid the pathogenic erythrocyte stage, P. falciparum has the capacity avoid location by controlling the antigens which coat the surface of the cell. The resistant framework experiences issues perceiving the parasite's antigenic varieties, and is accordingly not able to rapidly discard it (Craig et al., 2001). Amid the erythrocyte phase of the sickness, the erythrocyte may stick to the vascular endothelium, the dainty layer of cells within veins. This is thought to be one of the components which add to mortality, alongside the arrival of a different arrangement of poisons (Chen et al., 2000). Amid proliferation and development in the erythrocytes, a little extent of the abiogenetic merozoites believer to sexual cells which serve to immunize mosquitoes when they eat the blood (Miller et al., 2002). The anopheline mosquito serves as the vector which transmits the sickness to another human host. The merozoites replicate in the mid-gut of the mosquito before they move to the salivary organs, along these lines finishing the cycle (Talman et al., 2004). Along these lines, the abiogenetic parasites experience a puberty stage in human hosts, where they develop into sexual parasites, which then contaminate a mosquito.

There are current medication treatments for treating malaria. These for the most part fall into three classifications, in view of the centre segment of the medication: quinoline, antifolate, or artemisinin. Quinine, an alkaloid initially got from tree rind, is the most established powerful malaria treatment. It was found in cinchona trees found in Peru in the late seventeenth century (Greenwood, 1994). Quinine would later be utilized as the most widely recognized treatment until the 1960s, and soon thereafter different medications, for example, chloroquinine got to be accessible. Lately, multi-drug resistance has restored its convenience, and it is still in far reaching utilization, however in mix with different medications (Babalola et al., 1998). Proof recommends that the quinolines stifle malaria by hindering the polymerization of a poisonous heme called hemozoin that is discharged by the parasite, hence abating the procedure by which the agamic parasites develop, duplicate, and crack the erythrocyte (Sullivan et al., 1996).

Artemisinin is additionally accepted to restrain hemozoin or conceivably target different proteins in a contaminated cell; however its component is totally diverse. Examination recommends that Artemisinin is actuated by the high convergance of parasitic heme, making it discharge free radicals which avert polymerization (Meshnick, 2002). In spite of the mixture of medication medicines, then again, the rise of resistance decides the valuable existence of a specific treatment, and in this way affects the general expenses of controlling malaria.

Figure 2. Life cycle of Plasmodium (www.cdc.gov.com)

1.6 Sign and Symptom of Malaria

Malaria is an infectious disease transmitted to humans by the bite of female infected mosquitoes of the Anopheles genus. The pathogen which causes the malarial infection is a parasite protozoon of the Plasmodium genus. There are four species of this parasite: Plasmodium ovale, Plasmodium malariae, Plasmodium falciparum and Plasmodium vivax. They have similar symptoms and it is difficult to make species differentiation without laboratory studies. The main manifestation of the infection, the fever example takes after that seen in ahead of schedule phases of numerous other bacterial, viral and parasitic maladies. The initial three species (P. vivax, P. malariae and P. ovale) may bring about serious sickness, yet they are not really deadly. Nonetheless, the fourth specie (P. falciparum) causes a great deal more genuine and dynamic disease, other than it some of the time prompts unconsciousness and demise inside of a couple of days of malarial infection (Phillips 1983).

1.6.1 Clinical Symptoms

Plasmodium falciparum this parasite has been distinguished by numerous names: fall fever, dangerous tertian malaria, cerebral malaria (Phillips 1983, Knell 1991, APHA 1995). The hatching period is generally 7 to 14 days. It is the most genuine malaria disease which has fever (in non-resistant patients it surpasses 40 oC), chills, sweats, hack, looseness of the bowels, respiratory pain, migraine, stun, renal and liver disappointment, aspiratory and cerebral edema, trance state and passing. Case casualty rates among untreated kids and non-safe grown-ups surpass 10 % (FDROEMOH, 2004).

Plasmodium vivax, Plasmodium ovale and Plasmodium malariae in numerous regards, they may be gathered together as the "backsliding" malaria. They are not life debilitating aside from in the exceptionally youthful and extremely old individuals, and patients with simultaneous sickness or immunodeficiency. The hatching period is typically 10 to 15 days, however in a couple strains it may stretch out up to a few months. In the last 2 or 3 days of the hatching period, sickness may start with inconclusive disquietude and a gradually rising fever which goes on for a few days. This side effect is joined by cerebral pain, appendage torments, spinal pain, anorexia, and in some cases sickness and spewing. On account of vivax and ovale diseases, genuine backslides taking after periods with no parasitaemia may happen at sporadic interims for up to 5 years. In any case, on account of malariae disease, it may hold on for upwards of 50 years with repetitive febrile scenes (Phillips 1983, Brian 1989, APHA 1995).

1.7 Diagnosis

Finding of P. malariae malarial infection is specially made by the examination of fringe blood movies recolored with Giemsa stain. PCR systems are currently routinely utilized as a part of numerous research centers to affirm analyze and to particular blended malarial infection s. As of late, in Southeast Asia it has been demonstrated that malarial infection s with the monkey malaria parasite Plasmodium knowlesi in people have been misdiagnosed as being diseases with P. malariae (Jongwutiwes et al., 2004; Singh et al., 2004). Identification was affirmed by PCR. In this manner, cautious minute examination may not be adequate for positive affirmation in specific circumstances where monkey malaria parasites, for example, P. knowlesi or P. inui may be transmitted to people. In zones of South America where people and monkeys exist together, it is difficult to separate diseases of P. malariae from malarial infection s of P. brasilianumon the grounds that they might, actually, be one and the same. The first stages that appear in the blood are the ring stages that are formed by the invasion of merozoites released by rupturing liver stage schizont. As described by Coatney et al. (1971), these become gradually yet soon involve one-fourth to 33% of the parasitized cell. Shade increments quickly, and the half-developed parasite may have from 30 to 50 coal black granules. As the parasite develops, it accepts different shapes, and it frequently extends over the host cell to frame what is known as the band structure. These are regularly

viewed as demonstrative, despite the fact that they are here and there seen in different species. The host cell is not developed as the parasite develops to fill the tainted erythrocyte.

At about the 54th hour, division starts, and by the 65th hour, the host cell is almost filled and the parasite contains five or six chromatin masses; shade is scattered. The cores and cytoplasm start to discrete, and the color gets to be isolated and amassed in a free mass in the focal point of the phone encompassed by the pretty much symmetrically masterminded merozoites. The quantity of merozoites may be from 6 to 14, yet the normal number is 8. The full grown macrogametocyte has a thick, profoundly recoloring blue cytoplasm with a little red-recoloring core. The shade is scattered. The parasite totally fills the host cell. The cytoplasm of the grown-up microgametocyte has a light somewhat blue pink satin. The shade is restricted to the cytoplasm of the parasite. The core is diffuse, takes a pinkish-blue stain, and may involve a large portion of the contaminated cell. The parasite seems to involve the whole host cell. Usually, microgametocytes dwarf the macrogametocytes (Jongwutiwes et al., 2004; Singh et al.,2004).

1.7.1 Serological tests

Serologic tests are not sufficiently particular for indicative purposes but rather are fundamental epidemiologic apparatuses. They take into consideration the estimation of past presentation to disease. The immunofluorescent-neutralizer (IFA) system has been utilized to gauge the vicinity of antibodies to P. malariae. It was demonstrated that when a malarial infection was of brief time, the reaction soon declined. In any case, if the parasite tally recrudesced or reinfection happened, the IFA reaction rose to a higher lever and endured for a long time or years (Collins et al., 1964). Cross-response studies demonstrated that P. brasilianum, the monkey malaria parasite from South American monkeys that seems, by all accounts, to be indistinguishable to P. malariae, could be utilized as a part of serologic testing Plasmodium fieldi, a parasite of macaques from Southeast Asia, additionally cross-responded firmly with P. malariae (Collins et al.,1966). In a serological study of 498 sera collected from Nigerians, 43.2% had positive responses to P. brasilianum (Collins et al., 1967). The reaction was low in youngsters yet was equivalent to that to P. falciparum with sera from people 13 years old and more seasoned. In an investigation of a wilderness native territory in Malaysia, there was a practically finish nonappearance of P. malariae disease amid a parasitological review, while generally the rate was known not exactly high. The high rate of most extreme IFA reactions (51%) to P. malariae, be that as it may, was presumably more demonstrative of the malarial experience or of subpatent parasitemia than the slide study as a result of late medication mediations (Collins et al., 1968).

1.8 Treatment of Malaria

Because of provincial variety in medication affectability, against malaria chemotherapy is an exceptionally complex issue. In any case, by and large there is clear qualification

in the treatment of 1) The three backsliding malaria which are scarcely chloroquinine resistance, 2) Mild P. falciparum malaria in a semi-invulnerable or safe individual, and 3) An existence debilitating extreme P. falciparum malaria in non-safe kids and grown-ups (Whittle and Boele, 1994).

1.8.1 Artemisinin (Qingnasou)

Artemisinin is extremely dynamic against P. falciparum rings and also the later phases of the parasite. It is given orally or by rectal suppository and ought to just be utilized for treatment however not for prophylaxis (Whittle and Boele, 1994).

1.8.2 Chloroquinine

Chloroquinine is utilized for the treatment of the backsliding strains. It is normally taken orally. It remains the most perfect medication for treatment and prophylaxis as a result of its minimal effort and relative absence of reactions. On the other hand, P. falciparum has created imperviousness to this medication in many parts of the world (Whittle and Boele, 1994).

1.8.3 Halofantrine

Halofantrine is viable in multi-drug safe P. falciparum malarial infection. On the other hand, resistance is recorded in South East Asia. Henceforth, to treat P. falciparum, it requires multidose regimen (Whittle and Boele, 1994).

1.8.4 Mefloquine

Mefloquine is viable against multi-drug-safe strains; on the other hand, it is creating resistance in South East Asia. It is given orally in single measurements and it is viable in quickly clearing parasitamia and assuaging side effects. It is not prescribed for youngsters less than eight years (Whittle and Boele, 1994).

1.8.4 Primaquine

Primaquine is the main medication that is viable against the hepatic types of P. vivax and P. ovale. It ought not to be taken by pregnant ladies, kids under four years and any condition that inclines to granulocytopenia, for example, erythematosus (Whittle and Boele, 1994).

1.8.5 Fansidar (pyrimethamine + sulfadoxine)

Fansidar is utilized for the treatment of uncomplicated gentle to direct chloroquinine-safe P. falciparum malaria. In east Africa, Latin America and South East Asia, resistance has been produced. It is not suggested amid pregnancy and lactation (Whittle and Boele, 1994).

1.8.6 Quinine

Quinine is obnoxiously sharp medication. No contraindication to the oral organization of the medication inside of the above measurements (Whittle and Boele, 1994).

1.9 Immunity to Malaria

In spite of the fact that the term insusceptibility implies an exceptionally productive declaration of people against a malaria resistance is not a simple idea (Pampana, 1969). In various appealing sicknesses, the illness keeps going a double days or weeks inside the body of a person. At that point it leaves a successful and rarely long lasting cover against a further interference of the infection. It doesn't last the entire life and this type of workable resistance does not happen and full security against re infection is required (Pampana, 1969).

1.9.1 Innate immunity

This insusceptibility is essential or characteristic. The instrument of this invulnerability, however, is found in couple of people, and it comprises in decrease of the quantity of merozoites in the plasma. Due to this guard component a couple of the merozoites infiltrate to the erythrocytes. Because of diminishment in the increase of merozoites, there would be no advancement of disease (Whittle and Boele, 1994).

1.9.2 Acquired immunity

This sort of insusceptibility creates while the disease continues in the body of the tainted person. Gained resistance is initially uncovered in the recuperation from the essential assault without treatment, regularly while parasites are still present in the blood however in more noteworthy numbers than at the onset of the assault. This sort of insusceptibility is connected with the vicinity of parasite in the body of the person. Insurance from reinfection won't keep going long after the parasite vanished from the body (Whittle and Boele, 1994).

1.10 Epidemiology

Globally around 2 billion individuals are at danger for malarial illness. Per annum

back malaria has been a reality of death and life. Like different nations additionally in Pakistan, it is an essential issue and reason for mortality (Taylor et al., 2000).The WHO gauges that in 2010 there were 219 million instances of malaria bringing about 660,000

somewhere around 350 and 550 million for falciparum1.24 million up from 1.0 million passings in 1990. The greater part of cases (65%) happens in kids less than 15 years of age (Murray et al., 2012). Around 125 million pregnant ladies are at danger of disease every year; in Sub-Saharan Africa, maternal malaria is connected with up to 200,000 assessed newborn chi

(Hartman et al., 2010). There speak the truth 10,000 malaria cases for each year in Western Europe, and 1300 1500 in the United States (Taylor et al., 2000). Around 900 individuals kicked the bucket from the ailment in Europe somewhere around 1993 and 2003 (Kajfasz, 2009). Both the worldwide rate of infection and coming about mortality has declined as of late. Malaria is in the blink of an eye endemic in a wide band around the equator, numerous parts of Asia, and quite a bit of Africa; in Sub-Saharan Africa, 85 90% of malaria fatalities happen. An evaluation for 2009 reported that nations with the most astounding demise rate per 100,000 of populace were Ivory Coast (86.15), Angola (56.93) and Burkina Faso (50.66). A 2010 appraisal showed the deadliest nations per populace were Burkina Faso, Mozambique and Mali (Murray et al., 2012).

Malaria is a standout amongst the most generally appropriated parasitic infections in the tropics. In any case, on the globe it stretches out up to 60* north and 40* south of scopes. Its circulation on the planet is not uniform. Distinctive types of Plasmodium are found in diverse nations. Plasmodium falciparum is prevalently found in the warm and wet parts of Africa, the Middle East, Asia, Haiti, the Caribbean Islands, and Central and South America. Plasmodium vivax is overwhelming in the tropical and subtropical parts of Asia and in Eastern Africa and in some mild districts, for example, in the Middle East and Iran. It is not found in the locals of West African. In spite of the fact that P. malariae is a great deal less regular than P. falciparum and P. vivax, it is broadly circulated all through the tropics. Plasmodium ovale, which is phenomenal types of malaria, happens in Africa and South America (Brian, 1989, Whittle and Boele, 1994). The variety of malaria the study of disease transmission is not constrained by landmasses or between nations.

There is likewise variety in the dissemination of Plasmodium in a solitary nation. McGregor (1989) states two amazing events of malaria in distinctive parts of a nation. In one compelling malaria may be unsteady, happening in pestilences isolated by interims of low frequency of malaria. Precarious malaria happens when there is sudden advancement of circumstances which are conductive for the transmission of malarial infection at levels far over the typical time of event. For this situation it happens as an intense febrile sickness and it influences all age gatherings and result in high mortality and horribleness. At the other amazing malaria could be steady, in a manner that there is next to no distinction in the frequency of its event from year to year. In this condition, transmission is generally lasting and it assaults the group seriously. The most assaulted gatherings are youngsters, be that as it may, grown-ups normally create invulnerability and they are less influenced.

The study of disease transmission of malaria in a given nation is controlled by distinctive elements (Brain 1989, McGregor 1989). These are conductive situations for the transmission, the vicinity of suitable Anopheles mosquitoes, the vicinity of Plasmodium, and the vicinity of a store of the parasite. In some outstanding cases, there may be malaria without being satisfied the above conditions. This happens when the parasite is taken by explorers and foreigners while they are going from endemic territories. This sort of malaria is called imported malaria.

1.11 Malaria in Pakistan

Pakistan being a piece of endemic belt has an occurrence of one case for each thousand populaces. Serious malaria has been a noteworthy reason for mortality overall and P. falciparum is the principle species for the majority of these death cases (Kreil et al.,2000). Albeit moderately unprecedented in the created nations, malaria stays a standout amongst the most predominant diseases in the creating and immature world. It is a huge reason for dismalness and mortality not withstanding making a huge social and monetary weight. Today, the most imperative issue in the administration of malaria is medication resistance of P. falciparum to the different hostile to malarial medications and event of systemic intricacy (Zafar et al., 1985). An unfathomable arrangement of watering system is available in Pakistan, after overwhelming precipitation in storm a great deal of stagnant water giving a perfect situation to the rear the mosquito. The transmission of malaria stays consistently, yet turns out to be more serious after the downpours in the months of July to November (Khadim, 2002; Lathia et al., 2004).

Epidemiological information from distinctive districts of Pakistan is deficient to precisely assess the occurrence of different types of malaria. Dera Ismail Khan (D. I. Khan) with a hot atmosphere, arranged on the right bank of the waterway Indus, in the North KP Province (old NWFP) of Pakistan. Patients giving fever generally represent a demonstrative issue for the clinicians however require a brief reaction. Despite the fact that malaria is a typical reason for fever in this area, different irresistible ailments like enteric fever and tuberculosis are not extremely extraordinary (Murtaza et al., 2004; Khadim, 2002).

Regardless of this, the infection is assessed to bring about no less than 50,000 death out of an expected 500,000 reported Malaria disease cases consistently (IRIN=Integrated Regional Information Networks, 2007). In Nawabshah, out of 435 clinically associated cases with malaria, 144 patients (33.1%) were affirmed by vicinity P. falciparum (Murtaza et al., 2004). Abbasi and Sheikh (1997) mulled over 380 instances of cerebral malaria in children hospital Larkana and total 350 cases (92.1%) with P. falciparum and 30 cases (7.8%) because of P. vivax. Afridi et al. (1998) prominent 10.4% frequency rate of Malaria disease out of 2500 suspected cases at Akhunabad, Peshawar. Hozhabri et al. (2000) watched slide inspiration rate 5.9%with 65% instances of P. falciparum and 35% of P. vivax in kids, at Jhangra, Sindh. Bhalli and Samiullah (2001) displayed a survey of P. falciparum malaria disease. Jan and Kiani (2001) watched 7% slide energy with P. vivax 6.3%and P. falciparum 0.67% among the Kashmiri displaced people settled in MuzafarAbad. Akbar (2002) discovered high rate of P. falciparum when contrasted with P. vivax (65%vs 35%) among 100 positive kids for malaria infection at Baqai Medical University, Karachi. Mohammad and Hussain (2003) watched 70 people (6.8%) with constructive Plasmodium infection out of 1020 blood movies among all inclusive community of district Buner. There was a high frequency of P. vivax when contrasted with P. falciparum (5.7% vs. 1.0%). Murtaza et al. (2004) considered 3.1% slide energy with 58% P. falciparum and 42% P. vivax in Sindh. Jamal et al. (2005)

discovered high rate of P. vivax (62.5%) than P. falciparum (36%) in 200 kids at Department of Pediatrics, CMH, Attock. Mahmood (2005) analyzed 10-15% cases as malaria patients out of 50 to 70 patients seen on consistent schedule in Karachi. He likewise watched P. vivax to be two times higher than P. falciparum. Jalaluddin et al. (2006) examined intestinal sickness in 160 instances of kids in Mansehra and watched 142 affirmed cases experiencing P. vivax (92.2%) and 12 with P. falciparum (7.7%). Mahmood et al. (2005) concentrated on 348 patients with fever at Civil Hospital and Ankle Sria Hospital Karachi from August 2003 to December, 2005 and watched 35% positivity rate, with P. falciparum 88.5% and P. vivax 9%. Malaria infection in NWFP was examined and watched that cerebral malaria infection was (2000) watched slide energy rate 5.9% with 65% more normal in guys (64%) and most powerless gathering was pregnant ladies. Nizamani et al. (2006) contemplated the information of Provincial Malaria Control Program of Sindh and watched more than 68,000 slides reported positive for malarial parasites with a normal slide energy rate of 2.4%. Normal P. falciparum proportion in years 2004 and 2005 was 33% and 37.2% separately. Yearly parasite occurrence was unsuitably high and P. falciparum proportion was discovered expanding in numerous regions of Sindh. Idrees et al. (2007) while examining example of malarial infection at Ayub Teaching Hospital Abbottabad found that out of 1994 patients screened 145 (7.2%) were discovered tainted. P. vivax was found in the dominant part (72.4%). P. falciparum was the second basic species identified in 24.1% cases. Blended disease was found in 3.4% cases.

Rahim et al. (2014) conducted study of malaria prevalence in district Mardan Pakistan. They studied 845 malaria suspected cases in BHU Ghuddar (Mardan). The overall prevalence (13.9 %) was reported. In which differential wise rate of P. vivax were found high 41 (9.03%) in male while 26 (7.9%) were in female. They also showed age wise in which age group 5-14 total positive cases 30 (8.13%) were more prone to malaria followed by age group above 14. From his study it was clear that P. vivax is the common species circulating in district Mardan.

Rationale of study

P. vivax is the most common species found in Pakistan. The current study was conducted to determine the epidemiology of malaria in district Mardan and provide the base line information for government as well as for local population.

Objective

Objectives of the current study were to find out the prevalence rate of malarial infection in district Mardan. To determine sex wise, age wise, month wise and tehsil wise distribution of malaria infection

Chapter 2

2 Materials and Methods

2.1 Study area

District Mardan was famous for hospitality. The Headquarters of Mardan Division in KP province of Pakistan. Mainly Located an altitude at 34°12'0N 72°1'60E. The total area of district Mardan is 1632 square kilometers having 894.7 population densities. Mardan is an alliance of various residential communities meeting up to shape an expansive city.

The midyear period is greatly hot and warm. Suddenly the temperature rise in the month of May to June. High temperature was recorded in the month of June, August and September. The temperature achieves its most extreme in the month of June i.e. 41.5 °C. Because of serious development and counterfeit watering system, the territory is damp.

The temperature goes down from October onwards. The coldest months are December and January was recorded. The minimum temperature were recorded in the month of January is 2.1 °C.

Figure 3. Study area of district Mardan/Data collection centre (figure were modified through Google.com)

The number of inhabitants in Mardan region has expanded around four-fold subsequent to 1951. As per 1998 statistics it is 1.46 million contrasted with 357,000 in 1951, with a yearly rate increment of around 3%. The aggregate zone of the area is 1632 square kilometers having populace thickness of 894.7 persons for every square kilometer in 1.

2.2 Study design

A cross sectional study was design from 1st January-31st December 2013.

2.3 Data Collection

Data of the suspected malarial patients were collected from different (Health Care Centers/Rural Health Center/Basic Health Unit/Hospitals) (Figure 1) including Mardan Medical Complex, Mardan, district Head Quarter Hospital Mardan, tehsil Head Quarter Kattlang, Category-D hospital Shahbaz Ghary, Tehsil Head Quarter Taht Bhai, RHC Toro Mayyar, RHC Rustam, RHC Sher Gharh, RHC Pahloo dairy and RHC Mangah.

2.4 Inclusion criteria

All the patients admitted during the year 2013 in the selected treatment centers were included in the current study. The suspected patients have the common symptoms of malaria were further process for the identification of malaria parasite.

2.5 Sample collection procedure

Screening tests of all the suspected patients was conducted in the respective treatment centers. Sociodemographic and clinical examination was recorded. All the patients were referred to laboratory for collection of peripheral blood to be investigated for malaria.

2.6 Microscopy

Gold standard method i.e. smear examination for malaria parasite (MP) was performed. Thick and thin blood films were prepared and Giemsa staning was performed. The slides were stored for further examination.

2.7 Prevalence rate

The rate of prevalence was determined by using the following formula:

×100

2.8 Descriptive analysis

The descriptive analysis of the current data was done on the basis of age, sex, area and month wise distribution.

2.9 Statistical analysis and graphical Representation

For statistical analysis PHstat2 version 2.5 was used. The P-value below 0.05 was considered significant and graphical Representation Microsoft Excel-2007 and word 2007.

2.10 Ethical Approval

The current work was approved by the ethical research committee Advance Studies and Research Board (ASRB) and the prior permission was granted by the higher authority of the respective treatment centers of district Mardan.

Chapter 3

3 Results

The momentum study was affirmed by moral Research Board of Hazara University, Mansehra Pakistan, and afterward earlier development was taken from Mardan Medical Complex and Teaching Hospital Mardan amid accumulation of information.

Downright 11272 malarial associated patients was researched comprise with 7513 male while 3759 female were inspected amid first January to 31st December 2013 from the three tahsil of district Mardan. Out of these 766 (7.79%) were seen positive in which 335 (2.96 %) male were discovered tainted with malarial disease, in which 309 (92.2 %) were discovered P. Vivax and 26 (7.76 %) were discovered P. falciparum individually. While in female, 431 (3.83 %) were discovered contaminated with malaria in which 400 (92.8 %) were discovered P. Vivax and 31 (7.19 %) were discovered P. falciparum disease individually. Age Wise distribution of the information demonstrates that age group 0-20 was more prone to malaria infection with most elevated frequency rate in our study. Out of 766 positive instances of malaria the age group 0-20, total 363 (47.4 %), age group 21-40, total 283 (36.94 %), age group 41-60, total 103 (13.44 %) and age group 60 or more, total 17 (2.22 %) were revealed infection respectively. District Mardan Comprises into three tehsil which are tehsil Mardan, Kattlang and Taht Bhai. The outcomes demonstrate to us that tehsil Mardan was more infected when contrasted with other tehsils of district Mardan. Out of 766 the positive patients 366 (3.25 %) tehsil Mardan, 95 (0.84 %) and tehsil Kattlang and 305 (2.7 %) tehsil Taht Bhai respectively. Our result shows the information of the entire year. Out of these 40 (3.83 %), 77 (7.95 %), 93 (7.32 %), 41 (7.1 %), 89 (5.62 %), 62 (4.9 %), 51 (4.16 %), 59 (6.98 %), 85 (9.86 %), 70 (12 %), 54 (10.09 %), 45 (8.65 %) and 766 (6.79 %) were the predominance rate of the months from January to December respectively.

Figure 4. Flow Chart malarial infection in district Mardan

Total Suspected Malaria Patients 11272

Out of these 766 were positive

57 (7.44 %) were P. falciparum

709 (92.56 %) were P. Vivax

Age Wise Prevalence rate

tehsil wise Prevalence Rate

Gender Wise/Species

Prevalence Rate

Month Wise Prevalence Rate

Age Group 0-20, 363 (47.4 %)

Age Group 21-40, 283 (36.94 %)

Age Group 41-60, 103 (13.44 %)

Age Group 61 and above, 17 (2.22 %)

tehsil Kattlang, 95 (0.84 %)

tehsil Mardan, 366 (3.25 %)

tehsil Taht Bhai, 305 (2.7 %)

Male, 335 (2.96 %), 309 (92.2 %) P. Vivax and 26 (7.76 %) P. falciparum

Female, 431 (3.83 %), 400 (92.8%) P. Vivax and 31 (7.19%) P. falciparum

January, 40 (3.83 %)

February, 77 (7.95 %)

March, 93 (7.32 %)

April, 41 (7.1 %)

May, 89 (5.62 %)

June, 62 (4.9 %)

July, 51 (4.16 %)

August, 59 (6.98 %)

September, 85 (9.86 %)

October, 70 (12 %)

November, 54 (10.09 %)

December, 45 (8.65 %)

3.1 Differential Prevalence

The main aim of the present examination was differential commonness of Human Plasmodium infection. In this examination demonstrates that P. Vivax 709 (92.56%) were the most astounding recurrence and took after by P. falciparum 57 in district Mardan as indicated in (Table No. 1 & Figure No. 5) Table 2: Differential prevalence of human Plasmodium of district Mardan

Differential prevalence Frequency Percentage

P. Vivax 709 92.56P. falciparum 57 7.44Mix Species 0 0

Total 766 6.79

Table 1: Descriptive Statistics of the patients visited Health Care Units in district Mardan

N Min. Max. Mean Std. Deviation Variance

Skewness

Statistic Std. Error

Age 11271 1.00 98.00 25.0839 13.17903 173.687 .882 .023

Sex 11271 0.00 1.00 0.3337 .47155 .222 .706 .023

Positive/Negative 11271 0.00 1.00 0.0680 .25169 .063 3.434 .023

Negative/PV/PF 11271 1.00 3.00 1.0731 .27908 .078 3.957 .023

Valid N (list wise) 11271

Figure 5. Differential prevalence rate of malaria in district Mardan

3.2 Age wise prevalence

The present study examines age insightful dispersion for the age group conveyance the patients was put into the accompanying age groups included age group 1: 0-20 years, age group 2: 21-40 years, age group 3: 41-60 years and age group 4: 61 or more years. The outcomes demonstrated that high frequency of malaria cases 363 (47.4%) in age group 1: 0-20 years took after by 283 (36.94%) age group 2: 21-40 years, 103 (13.44%) in age group 3: 41-60 years and 17 (2.22%) age group 4: 61 or more years as indicated in the (Table No. 2 & figure No. 6)

Table 2. Age wise frequency of malria positive cases (n=766).

Age Group (Years) Frequency Percentage

0-20 363 47.421-40 283 36.9441-60 103 13.44

61 and above 17 2.22Total 766 100

0

100

200

300

400

500

600

700

800

900

P. vivax P. falciparum Mix Species Total

Differential Prevalance

Frequency Percentage

Figure 6. Age wise distribution of malarial infection

3.4 Descriptive wise prevalence

The present led ponder likewise examination for the gender wise orientation shrewd conveyance. The patients were dispersed by Gender orientation. Gender wise shrewd conveyance demonstrates that female were more defenseless to malarial infection in our study. Out of 766 the male tainted cases were 335 (2.96%) in which 309 (92.2%) were P. Vivax and 26 (7.76%) were P. falciparum. while in female 431 (3.83%) contaminated cases in which 400 (92.8%) were P. Vivax and 31 (7.14%) were P. falciparum as demonstrated in Table No. 3 & Figure No. 7).

Table 3: Gender wise and specie wise distribution of the positive malaria patients

Gender Positive Percentage P. Vivax

Percentage P. falciparum

Percentage

Male 335 2.96 309 92.2 26 7.76Female 431 3.83 400 92.8 31 7.19Total 766 6.79 709 92.56 57 7.44

0

100

200

300

400

500

600

700

800

900

0-20 21-40 41-60 61 and above Total

Age Groups

Frequency Percentage

Figure 7. Descriptive wise and differential wise prevalence of malaria

3.5 Tehsil wise prevalence

Another goal of my exploration additionally to examine the tehsil astute circulation. Area Mardan includes into three tehsil named as tehsil Mardan, tehsil Taht Bhai and tehsil Kattlang. The predominance rate was discovered high in tehsil Mardan 366 (3.25%) trailed by tehsil Taht Bhai 305 (2.7%) and tehsil Kattlang 95 (0.84%).

Table 4. Distribution of positive cases on the bases tahsil Wise (n=11272)

Tehsils Frequency Percentage

Mardan 366 3.25Kattlang 95 0.84

Taht Bhai 305 2.7Total 766 6.79

0

100

200

300

400

500

600

700

800

900

Positive Percentage P. vivax Percentage P. falciparum Percentage

Gender and species wise distribution

Male

Female

Total

Figure 8. Tehsil wise prevalence rate in district Mardan

3.6 Month wise prevalence

The primary goal of the present study was to research month shrewd prevalence rate in district Mardan. For this reason the information were dispersed by shrewd. Out of these 40 (3.83 %), 77 (7.95 %), 93 (7.32 %), 41 (7.1 %), 89 (5.62 %), 62 (4.9 %), 51 (4.16 %), 59 (6.98 %), 85 (9.86 %), 70 (12 %), 54 (10.09 %), 45 (8.65 %) from January to December. The most elevated pervasiveness was recorded in the month of November, October and September as demonstrated in Table No. 5 & Figure No.9).

Table 5. Month wise incidence of malaria cases gender wise or differential wise.

Months Total Positive (%)

Male Female *Pv *Pf Mix

January 1042 40 (3.83) 18 22 34 6 -- February 968 77 (7.95) 26 51 72 5 -- March 1269 93 (7.32) 42 51 86 7 -- April 577 41 (7.1) 21 20 36 5 -- May 1582 89 (5.62) 35 54 81 8 -- June 1265 62 (4.9) 25 37 59 3 -- July 1224 51 (4.16) 21 30 48 3 -- August 845 59 (6.98) 24 35 54 5 -- September 862 85 (9.86) 39 46 79 6 -- October 583 70 (12) 32 38 66 4 -- November 535 54 (10.09) 29 25 51 3 -- December 520 45 (8.65) 23 22 43 2 --

*Pf= P. falciparum; PV= P. Vivax

0

100

200

300

400

500

600

700

800

900

Mardan Kattlang Tkhat Bhai Total

tehsils of Distric Mardan

Frequency

Percentage

Figure 9. Descriptive, Monthly and differential wise prevalence of malaria

3.7 Statistical analysis

For statistical analysis PHstat2 version 2.5 was used. The P-value below 0.05 was considered significant.

Table 6. Statistical analysis of species wise distribution on gender wise through chi square test

Species Male Female P-value

P. Vivax 309 400 0.114243- non significant

P. falciparum 31 26

Table 7. Statistical analysis of age wise distribution through chi square test

Age group Positive Negative P-valve 0-20 363 4492 2.67E

-07 Significant

21-40 283 4874 41-60 103 1010

61 and above 17 130

0102030405060708090

10040

(3.

83)

77 (

7.95

)

93 (

7.32

)

41 (

7.1)

89 (

5.62

)

62 (

4.9)

51 (

4.16

)

59 (

6.98

)

85 (

9.86

)

70 (

12)

54 (

10.0

9)

45 (

8.65

)

1042 968 1269 577 1582 1265 1224 845 862 583 535 520

Dis

crip

tive

Wis

e P

reva

lanc

e

Differential wise prevalance

Month wise prevalance

Male

Female

Pv

Pf

Mix

Table 8. Statistical analysis of tehsil wise distribution through chi square test

Tehsil Positive Negative P-value

Mardan 366 4186 2.83E

-13significant

Taht Bhai 305 3722

Kattlang 95 2553

Table 9. Statistical analysis of month wise distribution through chi square test

Month Positive Negative P-value January 40 1002

1.24E-14

Significant

February 77 891March 93 1176April 41 536May 89 1493June 62 1203July 51 1173

August 59 786September 85 777

October 70 513November 54 481December 45 475

Chapter 4

4 Discussion

An epidemiological survey shows that malaria 2nd one infection after M. tuberculosis infection mainly bacterial infection regards as the responsible for mortality and death rate. In each year 300-500 millions medical cases were reported worldwide. In which the death rate were 1.5 to 2.7 millions. Age wise records shows that the most prone age group were 1-4 years in young Childs the death ratio was too high as other groups, mainly in Africa and outside countries (WHO, 2014).

Epidemiological studies shows that main infectious countries worldwide the first one was Africa followed by Srilanka, Brazil and Afghanistan. In this Infection P. falciparum was (75%) and P. vivax was (20%) responsible worldwide. Among malarial species the death ratio of P. falciparum were recorded high rate (Nadjm and Behrens, 2012). Since long time ago malaria has been a reality of death and life. Like other countries also in Pakistan, it is an important problem and cause of mortality (Taylor et al., 2000). Regardless of this, the infection is assessed to bring about no less than 50,000 death out of an expected 500,000 reported Malaria disease cases consistently (IRIN=Integrated Regional Information Networks, 2007). In Nawabshah, out of 435 clinically associated cases with malaria, 144 patients (33.1%) were affirmed by vicinity P. falciparum (Murtaza et al., 2004). Our study will contribute to the data regarding the epidemiology of this infection in district Mardan Khyber Pakhtunkhwa Pakistan.

Rahim et al. (2014) studied 845 malaria suspected cases in BHU Ghuddar (Mardan). The prevalence was (13.9 %). P. vivax were found high 41 (9.03%) in male while 26 (7.9%) were in female. Age group 5-14 total positive cases 30 (8.13%) were more prone to malaria followed by age group above 14. From his study it was clear that P. vivax isthe common species circulating in district Mardan.

Epidemiological data of Pakistan from different regions is insufficient to exactly evaluate the incidence of various types of malaria infection (Khadim, 2002). Our study will contribute to the data regarding the epidemiology of this disease in district Mardan Khyber Pakhtunkhwa. Total 11272 malarial suspected patients was investigated consist of 7513 male while 3759 female were examined during 1st January-31st December 2013 from the three tahsil of district Mardan. In our current study the overall prevalence was recorded (6.79%) In our current study the overall prevalence was recorded (6.79%) which were lower from others studies. Ahmad et al. (2013) reported (17.32%) prevalence rate while Hussain et al. (2014) and Rahim et al. (2014) reported 29% and 13.9% prevalence rate of malaria infection in human in Lal Qilla and district Mardan respectively. Hussain et al. (2015) results demonstrate that the prevalence rate was 10.29%. Tareen et al. (2012) study Malaria burden in human population of Quetta reported incidence of malaria was found to be 18.45% (338). The decrease in the ratio

of malaria infection shows that the malria is control and get rid of the disease from the district Mardan.

Differential wise prevalence was the objective the current research. The differential prevalence malaria our result revel that 709 (92. 56%) were P. vivax followed by P. falciparum which was 57 (7.44%). Yar et al. (1998) and reported high positive cases of P. vivax which was (60.50%) and low incidence rate of P. falciparum which were (11.03) while studying the prevalence of the malaria parasite in district Multan. Another study conducted by Rahim et al. (2014) found high rate P. vivax 41 (9.03%) in male while 26 (7.9%) were in female. Another study by Jan and Kiani (2001) have reported High Ratio of P. vivax (6.33%) and (0.67%) were P. falciparum in Kashmiri refuges settled in MuzafarAbad. Muhammad and Hussan (2003), conclude that high prevalence of P. vivax (5.78%) followed by (1.08%) were P. falciparum reported. The main reason for little varying results with other researcher due to Environment change, their geographic and socioeconomically region of Khyber Pakhtunkhwa. Present conducting study reported no cases of malaria infection with P. ovale and P. malariae species with same Yar et al. (1998) and in Multan by Yasinzai and kaharsulmankhel (2008).

According to this data, female 431 (3.83%) was more prone to malaria than male 335 (2.96%). We are reporting in contrast to other finder. Here in district Mardan has high incidence occure in female (Ahmad et al., 2013; Rahim et al., 2014; Muhammad and Hussan, 2003). Malaria prevalence in females in our study can be justified by the fact that immune system of the female was not so strong as compared to male. To determined the epidemiological of malaria infection in a set country by various factors (McGregor 1989, Brain 1989). The female were sticking to home have great chance of getting malaria infection then male. The second main reason was that Mardan is a joining of a large number of small towns coming together to form a large city means village life. District Mardan has vast irrigation system, after heavy rainfall in monsoon after heavy rainfall a lot of standing (stagnant) water which were an ideal environmental condition for mosquito breeding near home where the stagnant water of pond and can easily approach to female inside the living are to get malaria infection. The female also have restricted to home and not easily approach to hospital or health care centre.

Malaria affect and caused infection in all the age groups; still, the individual range of 0-21 years are more vulnerable to get malaria infection we reported 363 (47.4%) in the said age group followed by age group 21-40 years, 283 (36.94%), then followed by age group 41-60 and age group 61 and above years were 103 (13.44%) and 17 (2.22%) respectively. Our findings are comparable and with line up with before surveys in which they reported that 66.1% of malaria cases in the age group above 10 years (Yar et al., 1998) also another study by Rahim et al. (2014) in district Mardan in which age group 5-14 the positive cases 30 (8.13%) were more prone to malaria followed by age group above 14 years. The people to this age group are concerning in different skilled activities and interaction to mosquitoes bite as they remained outside during most part of day. Different incidence of malaria was reported amongst these age groups could

be attributed to the level, with the age of acquired immunity that increases, which may also be linked with defense from malaria infection.

In the month of September large numbers of malaria cases and incidence were reported while in February and March consider the small numbers of malaria case or incidence were reported in study. Pakistan mainly belongs to tropical country where the most of peoples have depended upon agriculture concerned vast irrigation system, after heavy rainfall in moonsoon after heavy rainfall a lot of standing (stagnant) water which were an ideal environmental condition for mosquito breeding (Hussain et al., 2014). In the moonsoon season from the month of July to November has reported great prevalence of malaria infection.

Tehsil wise distribution shows that prevalence of malaria infection found high in tehsil Mardan 366 (3.25%) followed by tehsil Taht Bhai 305 (2.7%) and tehsil Kattlang 95 (0.84%). The great incidence was found in tehsil Mardan the main reason is that the said tehsil was the largest tehsil of district Mardan, comprises urban area and most of rural area. Majority of the peoples in tehsil Mardan lived in village with low socioeconomic status, In rainy season the water accumulates and provides better condition for the mosquito breeding (Hussain et al., 2014).

Conclusions

From our study it was concluded that the general predominance was discovered moderate. The illness proportion was revealed high among the female subjected where age wise dispersion was report high in age between age group 0-21 years. P. vivax is the regular species and high proportion of malaria infection was accounted for in the month of September, October and November in district Mardan.

Recommendation Awareness regarding the disease is necessary for the control and eradication of malaria in district Mardan Further studies are recommended to explore the risk factors of the disease. A better management and case detection is necessary to get free the area from the malaria infection.

Chapter 5

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