Irrational use of antimalarial drugs in rural areas of eastern Pakistan: a random field study

Shafaat Yar Khan 0 Ahmad Khan 0 Muhammad Arshad 0 Hafiz Muhammad Tahir 0 Muhammad Khalid Mukhtar 0 Khawaja Raees Ahmad 0 Najma Arshad 1 0 Department of Biological Sciences, University of Sargodha , Sargodha , Pakistan 1 Department of Zoology, University of Punjab , Lahore , Pakistan Background: Prescription of antimalarial drugs in the absence of malarial disease is a common practice in countries where malaria is endemic. However, unwarranted use of such drugs can cause side effects in some people and is a financial drain on local economies. In this study, we surveyed the prevalence of malaria parasites in humans, and the prevalence of the malaria transmitting mosquito vectors in the study area. We also investigated the use of antimalarial drugs in the local people. We focused on randomly selected rural areas of eastern Pakistan where no malaria cases had been reported since May 2004. Methods: Mass blood surveys, active case detection, passive case detection, and vector density surveys were carried out in selected areas of Sargodha district from September 2008 to August 2009. Data pertaining to the quantities and types of antimalarial drugs used in these areas were collected from health centers, pharmacies, and the district CDC program of the Health Department of the Government of the Punjab. Results: Seven hundred and forty four blood samples were examined, resulting in a Blood Examination Rate (BER) of 3.18; microscopic analysis of blood smears showed that none of the samples were positive for malaria parasites. Investigation of the mosquito vector density in 43 living rooms (bedrooms or rooms used for sleeping), 23 stores, and 32 animal sheds, revealed no vectors capable of transmitting malaria in these locations. In contrast, the density of Culex mosquitoes was high. Substantial consumption of a variety of antimalarial tablets, syrups, capsules and injections costing around 1000 US$, was documented for the region. Conclusion: Use of antimalarial drugs in the absence of malarial infection or the vectors that transmit the disease was common in the study area. Continuous use of such drugs, not only in Pakistan, but in other parts of the world, may lead to drug-induced side effects amongst users. Better training of health care professionals is needed to ensure accurate diagnoses of malaria and appropriate prescription of antimalarial drugs delivered to communities. - Background Malaria is a major vector borne disease that is the second most prevalent disease in Pakistan. Its transmission is seasonal, with epidemic outbreaks in Baluchistan, Khyber Pakhtoon Khawa (KPK) and Sindh province. It is predominantly a problem in the Federally Administrated Tribal Areas (FATA) and along the border of Iran and Afghanistan. However, in Punjab, the most populous province, it is less common and the disease incidence is much lower than in other areas of Pakistan. The disease is transmitted by the bite of an infected female mosquito belonging to the genus Anopheles. A total of 577 species of Anopheles mosquitoes have been recorded in the world, of which 77 species act as vectors for malaria. In Pakistan, about 24 Anopheles species are known; of these only two are malaria vectors (Anopheles culicifacies and An. stephensi). Two new species, namely, An. fluviatilis and An. annularis are suspected of transmitting malaria in Baluchistan province [1]. Common symptoms of malaria include high fever, shivering, anemia, joint pain, vomiting and retinal damage. Health care professionals generally use these symptoms to diagnose malaria [2]. In addition, all pyrexia of unknown origin (PUO) with or without the above mentioned symptoms are generally treated as malaria when patients do not respond to antibiotics (and in the absence of a laboratory confirmed diagnosis). For effective malaria control in Pakistan, professional bodies must work within clear public health guidelines, have adequate funding, and the support of opinion leaders, especially the government [3]. Two species of malaria parasite, Plasmodium vivax and P. falciparum cause malaria in Pakistan. P. vivax is the most common species, constituting approximately 76% of diagnosed cases, out of 104, 454 confirmed cases, while the remaining 24% are due to P. falciparum, which causes the most dangerous form of the disease [1,4]. A large number of anti-malarial drugs are used to treat malaria all over the world. However, dose-related side effects include vomiting, nausea, (quinine, Mefloquine) fatigue, anorexia, dizziness, pulmonary toxicity (Mefloquine), neuropsychiatric effects (Mefloquine and Chloroquine), effects on the retina, blindness, (quinine), and neurotoxicity targeting mainly the auditory and vestibular pathway (artemisinin in combination with Mefloquine) [5-12]. Inappropriate use of antimalarial drugs by clinicians, general practitioners and health facilities is a common practice in many developing countries like Pakistan [13-15]. The problem is mainly related to a lack of training, and an absence of proper treatment guidelines and diagnostic facilities, especially in rural areas. Therefore, in areas where clinicians have no access to laboratory facilities, treatment is based mainly on clinical symptoms, which leads to overdiagnosis of malaria and excessive use of antimalarial drugs [16]. Mannan et al., [17] reported that 22.4% of patients treated with antimalarial drugs at health facilities in Khartoum, Sudan, did not present with fever, nor reported an attack of fever before presenting themselves for treatment; in addition, 35.4% of patients treated with antimalarials had malaria parasite negative blood films. Irrational prescription of antimalarial drugs, without laboratory confirmation of malarial disease, has also happened in Lahore, the second largest district of Pakistan (population > eight million); this observation provided the impetus to conduct the present study. While working for the communicable disease control program in the Lahore district, no evidence of malarial vectors or parasites were recorded (unpublished data) in most parts of the district; nevertheless, antimalarial use was observed on a large scale. The objective of the present work was to study the prevalence of malaria, the vectors that transmit it, and the use of antimalarial drugs in randomly selected rural areas of the Sargodha district in the eastern part of the country that has seen no malaria cases since May 2004 (monthly surveillance data of CDC, Punjab 200408). Methods Site selection The selected area for the study was the union council (UC) # 125 in the Sargodha district of Pakistan. This UC is a thickly populated rural area comprising six villages with a total population of 23,359. This area is a vast agricultural landscape with an organized irrigation system consisting of channels, canals and tributaries. This UC is a central point for the surrounding areas and therefore has a good number of health facilities, consisting of one public (...truncated)