ccording to the World Health Organisation, Pakistan is one of the seven countries in the Eastern Mediterranean Region that account for 98 per cent of the total malaria burden in the region.

Four species, including P vivax and P. falciparum, are known to infect humans in Pakistan and are the most common and widely distributed parasites. P. vivax represents the most predominant parasite (>80 per cent) in Pakistan.

Malaria is spread through mosquito bites from infected female anopheles mosquitoes. Occasionally, transmission occurs by blood transfusion, needle sharing, organ transplantation or from mother to fetus.

Malaria is endemic in Pakistan. It is unstable and spreads seasonally—transmission peaks twice a year, from September to December and April to May. Changes in climate, poor vector control and poor health facilities lead to a significant rise in malaria cases in Pakistan.

A rapid upsurge in cases was observed in Balochistan and Sindh after the devastating floods in mid-June 2022. From January through August 2022, more than 3.4 million suspected cases of malaria were reported in Pakistan, compared to 2.6 million suspected cases reported in 2021.

Manifestation

The first symptoms – fever, headache and chills – usually appear within 10–15 days after the infective mosquito bite and may be mild and difficult to recognise as malaria.

Other symptoms include vomiting, sweating, body aches and malaise. Complications include acute kidney injury, acute respiratory distress syndrome, mental confusion, seizures, coma and death.

Diagnostic tools

Any high-grade fever should be tested for malaria. Microscopy and rapid diagnostic tests help diagnose the disease. Rapid diagnostic test cassettes provide results in 20 minutes. In areas where test facilities are not available, empirical treatment for malaria is given to treat it timely and effectively.

Early diagnosis and treatment of malaria reduce disease severity, prevent deaths and contribute to reducing onward malaria transmission. WHO recommends that all suspected cases of malaria be confirmed using parasite-based diagnostic tests (through either microscopy or a rapid diagnostic test). Diagnostic testing enables health care workers to easily distinguish between malarial and non-malarial fevers, facilitating appropriate and timely treatment.

Prevention

Malaria prevention consists of a combination of mosquito avoidance measures and chemoprophylaxis.

Malaria is endemic in Pakistan. It is unstable and spreads seasonally—transmission peaks twice a year, from September to December and April to May.

A few steps have been recommended by the World Health Organisation and the Centre of Disease Control for dealing with mosquitoes. Because of the nocturnal feeding habits of anopheles mosquitoes, malaria transmission occurs primarily between dusk and dawn.

Mosquitoes rest in dark, humid places like under sinks, in showers, in closets, under furniture, or in the laundry room. Once a week, empty and clean, turn over, cover or throw out any items that hold water, such as vases or flowerpot saucers, to remove mosquito eggs and larvae. Repair windows and screens if they have holes to prevent mosquitoes from coming in through these. Use an indoor insecticide frequently. Tightly cover water storage containers so that mosquitoes cannot get inside to lay eggs. For containers without lids, use wire mesh with holes smaller than adult mosquitoes. When using insecticides, always follow label instructions. Repellents, coils and vapourisers should be used during the day both inside and outside the home (e.g., at work/ school) because the primary mosquito vectors bite throughout the day. Wearing clothes with full sleeves minimises exposure to mosquitoes. Governments should execute fumigation on a large scale.

Protection on the move

All travellers should use an effective mosquito repellent, such as those that contain DEET repellents. These should be applied to exposed parts of the skin. If travelers are also wearing sunscreen, they should apply sunscreen first and insect repellent second.

Chemoprophylaxis plays an important role in preventing malaria transmission among those travelling to endemic areas. All recommended primary prophylaxis regimens involve taking medicine before, during and after travel to an area with malaria. Beginning the drug before travel allows the antimalarial agent to be in the blood before the traveler is exposed to malaria parasites. The choice of drug depends on the status of health, pregnancy and lactation. Also, the duration of travel is important to consider. There are daily and weekly drug options available. The patient has to decide the best option after discussing it with the physician.

No antimalarial drug is 100 per cent protective; therefore, travellers must combine prophylaxis with mosquito avoidance and personal protective measures (e.g., insect repellent, long sleeves, long pants, sleeping in a mosquito-free setting, using an insecticide-treated mosquito net).

Safety lies in taking precautionary measures and educating the masses through social media and print media. Schools should take the initiative in spreading awareness among children. Hospitals should organise awareness programmes.

Vaccine

The WHO updated their recommendation for malaria vaccines in October 2023. The updated recommendation is applicable to both RTS, S and R21 vaccines:

WHO recommends the programmatic use of malaria vaccines for the prevention of P. falciparum malaria in children living in malaria-endemic areas, prioritising areas of moderate and high transmission. In areas with highly seasonal malaria or areas with seasonal peaks, countries may consider providing the vaccine using an age-based administration or seasonal administration. The governments should collaborate with health organisations to arrange funds and vaccine supplies.

The writer is a family physician