SOCIO-POLITICAL BACKGROUND



WHO/CDS/RBM/

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World Health Organization

Organisation mondiale de la Santé

DISTR: General and RBM Web site

4 October 2001

RBM Complex Emergency Malaria Data Base

AFGHANISTAN

Jayne Webster (Malaria Consortium), RBM EMRO and the RBM Complex Emergencies team, Geneva

For the

RBM Technical Support Network on Complex Emergencies

Malaria control in Afghanistan was compiled using available information. Apologies are extended to any agencies carrying out activities that have been omitted from this report. Additional information is welcomed for updating this report

Table of Contents

SUMMARY 5

1. SOCIO-POLITICAL BACKGROUND 10

1.1 Basic Indicators 10

1.2 Economic situation 11

1.3 Government type 11

1.4 Legal system 11

1.5 Ethnic groups 11

1.6 Religion 12

1.7 The complex emergency 12

2. Refugees and Internally Displaced People (IDPs) 12

2.1 History 12

2.1.1 Refugees 12

2.2.2 Internally displaced persons (IDPs) 13

2.2 Present Situation 14

2.2.1 Refugees 14

2.2.2 Returned refugees 15

2.2.3 IDPs 16

3. MALARIA SITUATION 18

3.1 Epidemiological 18

3.2 Environment and Transmission 19

3.3 Parasites 19

3.4 Malaria Burden 19

3.4.1 Prevalence surveys 20

3.4.2 Health facility based data 21

3.5 Malaria management 22

3.6 Drug resistance 24

3.7 Vectors 24

3.8 Insecticide resistance 25

3.9 Impact of the complex emergency 26

3.9.1 Refugees 26

3.9.1.1 Malaria in Northern Pakistan 26

3.9.1.2 Malaria in Iran 26

3.9.2 IDPs 26

3.10 Epidemics 27

3.10.1 Potential 27

3.10.2 Recent epidemics 28

3.10.3 Surveillance systems 28

3.10.4 Preparedness 28

3.11 Recent control measures Eastern Region 29

3.11.1 Clinical Management 29

3.11.1.1 Improved diagnostic and clinical services 29

3.11.2 Personal protection 29

3.11.2.1 Repellent 29

3.11.2.2 Insecticide treated mosquito nets (ITNs) 29

3.11.2.2.1 Health education and ITNs 30

3.11.2.2.2 Sales strategy 30

3.11.2.2.3 Promotion of ITNs 31

3.11.3. Urban control in Jalalabad city 31

3.11.3.1 Gambusia fish project 32

3.11.4 Community based malaria control 32

3.11.5 Cattle sponging 32

3.12 Recent control measures in other regions 32

3.13 Cultural factors 33

3.13.1 Perceptions of malaria 33

3.13.2 Traditional practises 33

3.13.3 Treatment seeking behaviour 33

3.14 Recommended prophylaxis and stand-by treatment for international staff 33

4. HEALTH SERVICES 34

4.1 Statistics 34

4.2 Health policy in relation to malaria 35

4.3 Coverage by health facilities 35

4.4 Access to health services by women 35

4.5 Health personnel, training and institutions 36

4.6 Health systems 36

4.7 Health partners 36

5. Miscellaneous 36

5.1 Suppliers 36

5.1.1 Nets 36

5.1.2 Insecticides 37

5.1.3 Drugs 37

5.1.4 Laboratory reagents 37

5.2 Key contacts 37

5.2.1 Agencies 37

5.2.2 MOPH 37

5.3 Key references 37

5.3.1 Reviews 37

6. PAKISTAN 38

6.1 Tent spraying during the acute phase of the emergency 38

6.2 Insecticide treated mosquito nets (ITNs) 39

6.3 Permethrin treated clothing or bedding 40

6.4 Other methods of personal protection 40

6.5 Indoor spraying 40

6.6 Livestock sponging 41

ANNEX 1    Health Facility, Infrastructure and Capacity 41

SUMMARY

DISEASE 1: MALARIA

|Infective agent |In Afghanistan 10-20% of all malaria cases are caused by Plasmodium falciparum. This is the most life |

| |threatening form of the disease. |

| |The remainder, 80-90% of cases, are caused by Plasmodium vivax, which causes the less severe form of disease. |

|Case definition |Uncomplicated Malaria |

| |Person with fever or history of fever associated with symptoms such as nausea, vomiting and diarrhoea, |

| |headache, back pain, chills, myalgia, where other infectious diseases have been excluded. |

| | |

| |Severe Malaria |

| |Person with fever and symptoms as for uncomplicated malaria but with associated signs such as disorientation, |

| |loss of consciousness, convulsions, severe anaemia, jaundice, haemaglobinuria, spontaneous bleeding, pulmonary |

| |oedema, shock. |

| | |

| |To confirm case: |

| |Demonstration of malaria parasites in blood films by examining thick or thin smears or by rapid diagnostic kit |

| |for P.falciparum. |

|Mode of transmission |Mosquito bite: Anopheles Superpictus is the main vector of importance. |

| |Other vectors present include: An. s stephensi, An. Culcifaces and An. Pulcherrimus |

|Incidence/prevalence in the |In 1999, on an estimated total population of 21 million people, over 12 million were estimated to be living in |

|area |areas with malaria risk, resulting in an estimated 2-3 million clinical malaria case. However, only, 395,600 |

| |cases were reported by the health services in that year. Approximately 80-90% of malaria cases is due to P. |

| |vivax and 10-20% is due to P. falciparum (with 300,000-450,000 estimated cases per year). |

|Geographical distribution |Malaria is endemic throughout Afghanistan at altitudes below 1500 m especially the rice growing areas, but it |

| |also occurs in urban areas such as Kabul and Jalalabad. The central highlands are malaria free. Transmission |

| |is dependent upon altitude, temperature and rainfall. |

| |Eastern zone: transmission is highest in rice growing areas. |

|Seasonality |Transmission is seasonal and unstable. Can be summarised as non-malarious to mesoendemic. |

| |In Afghanistan, vivax and falciparum malaria transmission is highly seasonal. Transmission starts normally in |

| |May/June, peaking in October-November, and diminishing rapidly in December with the onset of winter and |

| |corresponding drop in temperature. |

| |Transmission of vivax and falciparum malaria in Pakistan is year-round with seasonal peaks, mostly after the |

| |July-August monsoon. |

|Outbreak threshold | |

|Last epidemics in the area |In September 1999 there was a malaria outbreak in Nazian Eastern Afghanistan, the population of the areas is |

| |8,500 and up to 15% of the population were reported as having confirmed P.falciparum malaria. No deaths were |

| |recorded and the outbreak was controlled. In the same month there was a P.falciparum malaria outbreak in Qalai |

| |Nao of Badghis province. Out of 293 cases, 8 deaths were recorded. |

| | |

| |In November 1999 there was another malaria outbreak in Narang in Kunar Province. The population of this area is|

| |23,000 and the prevalence of P.falciparum was reported as over 30%. Two deaths were reported and the outbreak |

| |was controlled. |

| | |

| |Other outbreaks have been reported from the north of the country, in Faryab (22% P.falciparum prevalence), |

| |Heart, Baghlan and Kundus. No details of numbers affected or control measures are known. |

| | |

| |In September 2000 there was a P.falciparum malaria outbreak in Yakawlang district of Bamyan province with 15 |

| |deaths reported. |

|Factors that increase the risk |Major risk factors include: |

|of transmission | |

| |1. Population movement |

| |2. Sudden increase in vectorial capacity as a result of unusual weather |

| |3. Drug and insecticide resistance |

|- Mass migration |Yes: |

| |There is a potential for epidemics due to the movements of people in two forms. |

| |The influx of non-immune population (such as from the central highlands) into the malarious areas of the north |

| |(Faryab and Samangan provinces), the northeast (the whole region), the east (Nangahar, Laghman and parts of |

| |Kunar province), the south (Helmand and Kandahar provinces), the west (parts of Farah province, Shinand and |

| |Torghundi districts in Heart province). |

| |Introduction of a number of infected individuals into a malaria-free area. This was clearly demonstrated in |

| |Badghis province outbreak in 1999 that claimed 8 lives and also in Yakawlang outbreak in September 2000 that |

| |claimed 15 lives. It is believed that displaced people from the neighbouring Faryab province introduced the P. |

| |falciparum to Qalai Nao of Badghis province, while merchants from Yakawlang district who used to travel to |

| |Baghlan and Saripul provinces are thought to have introduced the parasite to those remote malaria-free |

| |villages. |

|- Mass aggregation |Yes: Increased risk of transmission |

|- Not access to health services|Yes: Delays in access to effective treatment increase likelihood of severe disease and death developing, as |

| |well as increase the human pool of malaria gametocytes (mature parasite stage in humans that once pick up by a |

| |mosquito then develops into the infective stage for transmission to another human) thus increasing |

| |transmission. |

|- Reduction of food intake |Yes: During widespread malnutrition people are more vulnerable to developing severe malaria (once infected) and|

| |case management is complicated, resulting in increased mortality. |

|- No availability of safe water|No |

| |However, temporary surface water is key breeding site for malaria vectors and should be reduced avoided or |

| |controlled where possible. |

|- Others |Lack of effective shelter increases exposure and therefore may increase number of infective mosquito bites per |

| |night |

| |Lack of preventive interventions such as insecticide treated materials (bed nets, sheeting etc) and residual |

| |insecticide spraying of shelters can increase risk of transmission significantly |

| |Insecticide resistance |

| |Drug resistance: The spread of chloroquine resistance due to widespread practices of self-medication and |

| |non-compliance with treatment regimes is now widespread. |

| |Sudden increase in vectorial capacity as a result of unusual weather |

| |Many parts of the country were stricken by drought and witnessed prolonged periods of abnormal warm weather |

| |during the past two years. Unusual/unseasonal meteorological conditions are believed to have increased vector |

| |capacity and subsequent malaria transmission in the Yakawlang epidemic (2,400 meter). |

|Risk assessment conclusions |The majority of malaria case will be caused by P. vivax, which is rarely life threatening. The minority of |

| |cases will be P. falciparum which can cause severe disease and death. |

| |The peak season for malaria is October/November in this region. There are estimated to be over 3 million |

| |displaced, many fleeing highland areas (with less malaria) and moving to, or through areas of higher malaria |

| |transmission. This specific group of displaced has low immunity to malaria displaced from these and increased |

| |risk for the next 6-7 weeks. |

| |Long term drought across the country has resulted in increasing malnutrition. All malnourished are at increased|

| |risk of disease, particularly young children. |

| |Those communities displaced to border regions of Pakistan and Tajikistan where malaria transmission is greater |

| |are most at risk both during the remaining transmission period and from the start of the new transmission |

| |season in April/May |

|Control and response measures |Good access to effective diagnosis and treatment of existing cases (see WHO emergency treatment |

|(including treatment and |recommendations) |

|vaccination) |Vigourous health education at community level to improve rapid treatment seeking behaviour |

| |Intermittent preventive therapy (with SP) for pregnant women where possible |

| |Effective prevention approaches to reduce risk of infection include; residual insecticide spraying of shelters,|

| |insecticide treated materials programmes (ITNs & Chadors) and cattle sponging. |

List of Tables

1. Basic indicators of the population

2. Ethnic groups of Afghanistan

3. Refugee returns for 1997 and 1998

4. Comparison of the basic indicators of the countries of asylum with those of Afghanistan

5. Numbers, origin and place of displacement of Internally displaced people (IDPs) in 1999

6. Malaria prevalence surveys in Eastern Zone October to November 1998

7. Health facility data from 5 Northern Provinces April 1991 to December 1994

8. Annual reported malaria cases in Afghanistan (Jan-Dec 1999)

9. Major vectors of Afghanistan: breeding places, biting and resting habits

10. Health service statistics

List of Maps

1. General position of Afghanistan

2. Areas of return of refugees (to the beginning of 1996)

3. Settlement areas of Afghan refugees in Iran and Paskistan

4. Relief map of Afghanistan showing low-lying areas with increased risk for malaria

Acronyms

An. culcifaces Anopheles culcifaces

An. pulcherrimus Anopheles pulcherrimus

An. stephensi Anopheles stephensi

An. superpictus Anopheles superpictus

ARC Afghan Relief Committee

CHA Coordination of Humanitarian Assistance

DDT Dichlorodiphenyltrichlorethane

HNI HealthNet International

HNI/MCP HealthNet International Malaria Control Programme

ICRC International Committee of the Red Cross

IDP Internally Displaced People

IIRO Islamic International Relief Organisation

IMR Infant Mortality Rate

ITN Insecticide Treated Mosquito Net

MOPH Ministry of Public Health

MRC Malaria Reference Centre

NGO Non Governmental Organisation

NWFP North West Frontier Province

OPD Out Patients Department

P.falciparum Plasmodium falciparum

P.vivax Plasmodium vivax

RBM/EHA Roll Back Malaria/Emergency and Humanitarian Aid

SCA Swedish Committee for Afghanistan

UNHCR United Nations High Commissioner for Refugees

UNOCHA United Nations Office for the Coordination of Humanitarian Affairs

WFP World Food Programme

WHO World Health Organization

AFGHANISTAN

Map 1 : General position of Afghanistan

1. SOCIO-POLITICAL BACKGROUND

1.1 Basic Indicators1,2,3

Table 1: Basic indicators of the population

|Total population (1998) |21,354,000 |

|Average annual growth rate (1978-1998) |2.5 |

|Age distribution 15 years can read and write % (1995) | |

| Male |47 |

| Female |15 |

|Urban population % of total population (1999) |25 |

1.2 Economic situation 3

Afghanistan is an extremely poor country highly dependent on farming and livestock raising (sheep and goats). Gross domestic product has fallen substantially over the last 20 years because of the loss of labour and capital and the disruption of trade and transport. Much of the population continues to suffer from insufficient food, clothing, housing, and medical care. Inflation remains a serious problem throughout the country. Government efforts to encourage foreign investment have been unsuccessful. Numerical data are either unavailable or unreliable. Afghanistan’s infrastructure and industrial base have disappeared and there is little for former refugees to do but survive on subsistence agriculture and small-scale trade.

1.3 Government type

Transitional government

1.4 Legal system

A new legal system has not been adopted, but all factions tacitly agree they will follow Shari’a (Islamic Law)

1.5 Ethnic groups 4,5

Table 2: Ethnic groups of Afghanistan

|Ethnic Group |Number |Location |Language |

|Pashtun |7 million |Mainly eastern and southern |Pashto |

| | |Afghanistan, Kabul, NWFP Pakistan | |

|Tajik |3.5 million |North eastern Afghanistan, Heart and|Dari |

| | |Kabul | |

|Hazara |1.5 million |Hazarajat, Kabul, Mazar-e-Sharif, |Dari dialect |

| | |Quetta & Baluchistan (Pakistan) | |

|Uzbek |1.3 million |Northern provinces of Jowzjan, |Uzbeki (Turkic) |

| | |Balkh, Baghlan and Kunduz between | |

| | |the Amu Darya and the Hindu Kush | |

| | |range | |

|Aimaq |800,000 |North western provinces |Dari |

|Turkmen |Estimates |Northern and north western provinces|Turkmeni |

| |125,000 to |bordering Turkmenistan | |

| |600,000 | | |

|Baluch and Brahui |300,000 |Southwest bordering on Iran and |Baluchi, Pashto |

| | |Baluchistan/Pakistan | |

|Nuristani |100,000 |Nuristan, eastern Afghanistan |Nuristani |

|Kuchi |Estimates 500,000|South western Afghanistan on borders| |

| |to 3 million |with Iran and Pakistan | |

The people of Afghanistan are ethnically, religiously and linguistically mixed.

1.6 Religion

80% Sunni Muslim and 20% Shi’a

Sunni Muslim is the dominant faith

1.7 The complex emergency

1979. December: Soviet troops invade Afghanistan

1989. February: Soviet troops withdraw from Afghanistan

1992. April: Mujahidin government takes power in Kabul

1994. November: Taliban capture Kandahar

1995. September: Taliban capture Heart

1996. September: Taliban capture Jalalabad and Kabul

1997. Taliban capture Mazar-e-sharief and then lose it to the opposition

1998 Taliban recapture Mazar-e-sharief

1998 Taliban capture Bamyam province and the rest of the highlands

2000 Taliban capture Taloqan the capital of Takhar province

The relationship between the Taliban regime, and both NGOs and UN agencies has been tense. The Taliban has always viewed the influences of the West as a treat to Afghanistan’s religious tradition.

In November 1999, the United Nations (UN) imposed limited sanctions against the Taliban regime. This caused frustration amongst Afghans, and attacks on UN buildings in urban centres including Kabul and Jalalabad were reported. Since the 11 September 2001 attacks on the USA and the increasing treat of an international attack on terrorist groups in Afghanistan most international agencies have evacuated.

2. Refugees and Internally Displaced People (IDPs) 4,5

2.1 History

2.1.1 Refugees

1978 People’s Democratic Party of Afghanistan (PDPA) took power through a military coup, resulting in the fleeing, within one year, of 400,000 Afghans to North West Frontier Province (NWFP) in Pakistan and 200,000 to Iran.

1979 December – Soviet troops enter Afghanistan, within one year 1.9 million refugees had left Afghanistan.

1985 –1990 according to UNHCR figures 6.2 million Afghans were living in Pakistan and Iran alone (includes children born in exile)

1989 February - Soviet troops withdrew from Afghanistan, many families who had spent the war in the mountains returned to their villages. But only small numbers of people returned from Pakistan and Iran.

April - Mujahidin government took power in Kabul and refugees return from NWFP Pakistan on a massive scale. Refugees also started to return from Iran

1994 continued conflict inhibited further return of refugees from Iran. The capture of Kandahar by Taliban in November brought about the return of a number of refugees from Pakistan.

1995 capture of the whole of Western Afghanistan by Taliban brought the return of refugees from Iran to a halt, thousands of people returned to Iran

The areas of refugee return upto the beginning of 1996 are shown in Map 2 below. It can be seen that the highest numbers of refugees returned to the Eastern Zone (30 to 50%), followed by 20 to 30% to Southern and Western districts of Afghanistan.

1996. 50,000 fled to Pakistan upon the capture of Jalalabad and Kabul by Taliban. Refugees began to return to southern Afghanistan, as the Taliban brought about security there.

2.2.2 Internally displaced persons (IDPs)

1989. Many families spent the years of the Soviet occupation in the relative safety of the mountain areas.

1992 the first major movement of IDPs to Mazar-i-Sharif following the rocketing of Kabul

1994 heavy rocketing of Kabul resulted in the development of two enormous refugee camps near Jalalabad and a further exodus to Peshawar NWFP

1996. Capture of Jalalabad and Kabul by the Taliban

1997. Capture of Shomali plains north of Kabul by Taliban causes 200,000 to flee to Kabul

1999,2000 Drought resulted in loss of livestock and displacement of Kushi (nomad tribes) to the western, southern and northern provinces. There are 50,000 IDPs in Heart in 6 camps.

2000 Capture of Taloqan causes mass exodus to Faizabad, the capital of Badakhshan province. There are also 114,000 IDPs on the river islands north of Kunduz fleeing the conflict.

An estimated one million Afghans have been internally displaced in the last 5 years alone. Since 11 September 2001 several million people have fled towns and villages of origin fearing a military attack.

A co-operation and resource-sharing agreement between ICRC, UNHCR, UNOCHA and WFP was signed in 1997. Under the agreement ICRC was designated the ‘reference’ agency for IDP issues in Afghanistan.

Map 2 : Areas of return of Refugees (to the beginning of 1996) 6

2.2 Present Situation

2.2.1 Refugees

Since 1978 over 6 million refugees have left Afghanistan mainly to the neighbouring countries of Pakistan and Iran, but also to Europe, North America and India.

The positions of the main refugee areas in Iran and Pakistan are shown in Map 3 below.

It can be seen that the main areas of refugee settlement in Pakistan were on the borders with Afghanistan, whereas in Iran they were in the midst and to the west of the country, including along the border with Iraq.

Map 3: Settlement areas of Afghan refugees in Iran and Pakistan 6

2.2.2 Returned refugees

Table 3: Refugee returns for 1997 and 1998 7

|Country of asylum |Returns 1997 |Returns 1998 |

|Iran |2,000 |14,000 |

|Pakistan |84,500 |93,200 |

Of the 107,000 refugees that returned to Afghanistan in 1998, nearly 90% of them returned from Pakistan.

During the first 10 months of 2000, some 128,588 refugees have voluntarily returned from Iran, and there have been another 25,000 spontaneous repatriates from Iran. During this same time period 53,018 refugees repatriated from Pakistan. Repatriations from both countries are still ongoing (source UNCHR).

Table 4 compares the basic indicators of the most prominent countries of asylum with that of the country of origin. It can be seen that the IMRs in Pakistan and Iran are less than 50% and 25% respectively of the rate in Afghanistan. The MMRs are 20% and 7%, in Pakistan and Iran respectively, of the rate in Afghanistan.

Table 4: Comparison of the basic indicators of the countries of asylum with those of

Afghanistan 1,2,3

| |Afghan-istan |Pakistan |Iran |

|Total population (1998) * 1,000s |21,354 |148,166 |65,758 |

|Average annual growth rate (1978-1998) * |2.5 |3.1 |3.0 |

|Age distribution 15 years can read and write % (1995) # | | | |

| Male |47 |50 |78 |

| Female |15 |24 |59 |

|Urban population % of total population (1997) # |25 |36 |60 |

Literacy rates for males are comparable in Afghanistan and Pakistan, but are 38% higher in Iran. Literacy rates for females are 38% and 75% higher in Pakistan and Iran respectively, than they are in Afghanistan. There is a much higher difference in the literacy rate of males and females in Afghanistan, followed by Pakistan and then Iran, female literacy as a percentage of male literacy being 32%, 48% and 76% in Afghanistan, Pakistan and Iran respectively.

The degree to which the conditions reflected in the basic indicators of the countries of asylum will affect the refugees is dependent, to a large extent, upon the degree of integration in the host country. In Pakistan and Iran most of the Afghan refugees were accommodated in camps which often provided better health services than were available to the surrounding local populations.

2.2.3 IDPs 8

The main area of conflict in 1999 was Shomali, Panshir and surrounding areas, north of Kabul. This resulted in movements of IDPs from these areas to Kabul, Northern and Northeastern Afghanistan (Table 5).

Table 5: Numbers, origin and place of displacement of IDPs in 1999

|Time Period |Origin |Number of IDPs |Place of displacement |

|New Displacements |

|March – May 1999 |Bamyan |115,00 |Neighbouring districts |

| | | |and Northern Afghanistan |

|July 1999 |Shomali Valley, Northern |100,000 – 150,000 |Kabul, Panshir Valley, |

| |Kunduz and Takhar | |Northern and North |

| |Provinces | |Eastern Afghanistan |

|Registered IDPs |

|August – November 1999 |Keshem, Rustaq, Dasht |16,525 |North and Central |

| |Qala, Chah Ab, Khaje | |Highlands |

| |Bahuddin, Khaje Ghar, | | |

| |Dasht Archi, Imam Saheb, | | |

| |Nahrain, Shomali Valley, | | |

| |Hezarejat and Darre Soufe| | |

| |Khaje Ghar, Dasht Archi, |22,345 |Kunduz |

| |Imam Saheb and Shomali | | |

| | |7,893 |Pul-i-kumi |

|IDP returns |

|June – September 1999 |Returned to Bamyan |87,000 |Neighbouring districts |

| | | |and Northern Afghanistan |

The currently escalating treat of international military strikes in Afghanistan is causing mass population displacement internally. UNDP projections (28 September 2001) estimate that over 3 million people are newly displaced.

3. MALARIA SITUATION

Malaria control activities were historically the responsibility of the Institute of Malaria and Parasitic Diseases (IMPD). Before the war, IMPD comprised a network of 8 regional reference centres and some 326 provincial and district satellite units all over the country. This network was able to launch a successful vertical control programme during the eradication era. Following the eruption of the civil war in 1979, the IMPD structures gradually disintegrated and finally collapsed. Only 33 centres (including the regional centres) remained functional.

A decentralised health system approach for health care delivery in Afghanistan within the framework of primary health care was adopted in 1994. Eight regional directorates for health were established.

The health sector is fragmented among the different stakeholders (MOPH, UN Agencies, some 54 international and national NGOs, and the private sector). The ‘Principled Common Programming (PCP)’ and many other bilateral/multilateral coordination mechanisms, e.g. The Technical Coordination Committee (TCC), provide for addressing vital health issues and also enhance the speedy revival of the disrupted health systems as well.

In 1998 the IMPD’s network in the eight regions was merged with the MOPH structures. Diagnosis and management of malaria became the responsibility of the general health services while the regional/provincial Malaria Reference Centres (MRC) retained the specialised antimalarial activities.

Assisted by the aid community, the IMPD in Kabul and the MRCs in Jalalabad, Kandahar, Mazar-e-sharif, Badakhshan, and Heart were able to carry out some vector control activities, including ITNs distribution, cross-checking of malaria slides, surveillance and training activities.

3.1 Epidemiological

Transmission is seasonal, unstable and dependent upon altitude, temperature and rainfall.

Transmission occurs below 2000m, the relief Map 4 below identifies the major areas where malaria may be a problem (note this map identifies areas of risk by altitude only). Such areas include those around Jalalabad and Khost to the east, Kandarhar to the south, Farah and Herat to the west and Mazar-i-Sharif, Kunduz, Baghlan and Pul-i-Kumri to the north.

The resulting endemicity in Afghanistan can be summarised as meso to hypoendemic in low-lying areas and non-malarious at higher altitudes.

The immune status of the population and thus likely severity of a clinical attack of malaria will depend on previous exposure. However, due to the seasonality of malaria in Afghanistan it is unlikely that immunity has a large role to play in protection against clinical malaria.

3.2 Environment and Transmission

Altitudes up to 1900m for P.falciparum and 2300m for P.vivax are warm enough in July to support malaria transmission. However, changes in climatic patterns appear to be increasing the altitude range for P.falciparum. P.vivax is able to survive the long winter periods due to relapses. The altitude ranges will vary with latitude, with altitudes being lower in the north and higher in the south 9. Generally, in the north below 1300m the transmission season for P.falciparum starts in May-June peaks in October/November and ends in December.

It can be calculated from the above that approximately 60% of the Afghan population live in areas with a potential risk of both P.falciparum and P.vivax, with a further 30% having a risk of P.vivax alone 10. However, the altitude limit in Afghanistan needs more investigation. Abnormal meteorological conditions may have been the trigger for a P. falciparum malaria epidemic at an altitude of 2,400 metres. This occurred in September 2000 in Yakawlang district of Bamyan province, there were 15 deaths.

A major determining factor for malaria in Afghanistan is the presence of paddy fields. Rice remains under water from June to August in some areas and it is in these areas where prevalence of P.falciparum is highest. Another important factor is that Afghanistan consists of huge arid areas surrounding ancient and well-developed irrigation systems. These irrigation systems however, are usually poorly maintained, and provide opportunities for mosquito breeding.

3.3 Parasites

P.vivax >85%, P.falciparum up to 15%

3.4 Malaria Burden

% OPD attendance due to malaria In Eastern zone: 15-30%

% admissions due to malaria No data

% deaths due to malaria Low – generally but may occasionally be high due to outbreaks

The exact number of deaths due to malaria is not known but generally felt to be few. However, in Kunar Province 1997 there were 7 reported deaths of children during a confirmed malaria outbreak. Others include 8 reported deaths from Badghis province in 1999 and 15 reported deaths from Yakawlang district in Bamyan province in September 2000.

The prevalence of P.falciparum and P.vivax cases varies by season due to altitude and temperature. In the low-lying areas of Eastern Afghanistan (Nangahar, Kunar and Laghman) most cases of P.falciparum malaria are found from October through to December. In contrast, P.vivax cases rise from April through to June/July, they then decrease through to September and rise again in October for a short time before decreasing in November.

[pic]

Map 4: Elevation map of Afghanistan showing low-lying areas with increased risk for malaria 11

3.4.1 Prevalence surveys

A national survey was conducted in 999 through collaboration between HealthNet International and WHO in 20 provinces from 5 Zones the results are presented in Table 6.

Table 6: Malaria prevalence surveys in Eastern Zone October to November 1999 12

|Province |Total Slides |% |% P.falciparum |Total malaria (%)|

| |Examined |P.vivax positive |positive | |

|Central |1752 |0.4 |0.5 |0.9 |

|East |9415 |4 |6.4 |10.5 |

|North |2067 |1.5 |3.8 |5.3 |

|South |4058 |1.5 |0.8 |2.4 |

|West |576 |0.5 |2.3 |2.8 |

|Total |17868 |2.8 |4.1 |6.9 |

Total slide positivity varied from 10.5% in the East to 0.9% in Central, whilst P.vivax positivity varied from 4% in the East to 0.4% in Central, and P.falciparum positivity from 6.4% in East to 0.5% in Central. This survey was carried out in October/November which is peak P.falciparum season.

N.B. The year 2000 study began in October and is ongoing.

3.4.2 Health facility based data

HNI routinely collect data from the network of clinics involved in malaria diagnosis and management in Eastern Zone, they also quality control the microscopy performed in these clinics. The P.vivax and P.falciparum positivity rates from health facility based data collected in Nangarhar Province between October and December 1998 are presented in Table 7. Slide positivity of P.vivax varied from 5.4% to 41.6% and P.falciparum ranged from 0.1% to 20.2%.

Statistics from health facility based data in 5 Northern Provinces was collected between April 1991 and December 1994 and reported.

Table 7: Health facility data from 5 Northern Provinces April 1991 to December 1994 13

|Province |Total Slides |Total Slides |% Positive |% P.vivax positive|% P.falciparum positive|

| |Examined |Positive | | | |

|Balkh |60,594 |6,111 |10.1 |8.0 |2.1 |

|Jawzjan |29,364 |2,754 |9.4 |8.9 |0.5 |

|Faryab |49,577 |8,697 |17.5 |16.7 |0.8 |

|Samangan |13,279 |253 |1.9 |1.5 |0.4 |

|Sar-i-Pul |9,086 |1,984 |21.8 |21.8 |0 |

Slide positivities of P.vivax ranged from 1.5% in Samangan to 21.8% in Sar-i-Pul, and P.falciparum of 0% in Sar-i-Pul to 2.1% in Balkh.

However, as this data is averaged out over a period of two and a half years, it is difficult to interpret. Transmission periods of P.falciparum are likely to be short. This will result in any significantly high slide positivity rates in transmission periods being masked by the higher number of months with no transmission and very low slide positivity rates.

More recent health facility data (1999) is presented in Table 8 below:

Table 8: Annual reported malaria cases in Afghanistan (Jan-Dec 1999)

|Region |Total Slides Examined |Total Slides |P. vivax |P. falciparum |Mixed |Clinical |Total |

| | |Positive | | | | | |

|Central |83 |58825 |14785 |442 |10 | |15237 |

|Eastern |100 |137132 |45237 |3829 |163 |22239 |71318 |

|Southern |16 |48500 |10615 |1099 |221 | |11935 |

|Western |57 |52447 |18311 |645 | |20297 |39253 |

|Northern |5 |44739 |19866 |1375 |21 |21262 |42524 |

|S. eastern |23 | |3246 |460 |49 |4591 |8346 |

|Kunduz Province |11 |119519 |42859 |5358 |4 |11723 |59944 |

|Baghlan Province |8 |54453 |31079 |1966 |80 |3738 |36863 |

|Badakhshan Prov. |19 |40022 |30032 |2562 |36 |4253 |36883 |

|Takhar Province |12 | |56191 |16611 |476 | |73278 |

|Grand Total |334 |555637 |272221 |34347 |1060 |88103 |395581 |

3.5 Malaria management

Lack of adequate national resources and the fact that the country is, at large, dependent on the aid community necessitated the search for a formula that incorporates efforts of the major stakeholders (UN agencies, the NGOs community, and the regional health authorities). WHO brokered the adoption of a collaborative approach through formation of Malaria Technical Committees. Four regions have so far established their committees. These committees are assigned to take the lead in planning and implementation of malaria control activities, within the context of the PHC and regional health structures. The “Principled Common Programming” and the TCC are expected to further enhance malaria combat efforts within a wider approach for health sector development.

The MOPH, UN agencies, and NGOs (March 1999) developed a five-milestone plan for antimalaria activities as follows:

Disease management based on early diagnosis and prompt treatment.

Disease prevention.

Epidemic preparedness.

Strengthened surveillance system.

Community mobilization and participation.

The guidelines for preparation of this plan was developed by WHO Afghanistan taking into account the realities of the local epidemiology of malaria in Afghanistan.Countrywide MOPH facilities and most NGO run facilities follow WHO recommended antimalarial drugs and guidelines for Afghanistan. Emergency treatment recommendations have been developed for this crisis and are attached as an annex.

Achievements During 1999:

Disease management:

Provision of supplies:

Antimalaria drugs and other supplies were pre-positioned in the eight regions before the

start of the transmission season. (See annexed WHO distribution list).

334 health facilities nation-wide received regular and uninterrupted supplies of drugs and other supplies provided by WHO and NGOs throughout the transmission season.

8 Malaria Reference Centres were provided some necessary equipment and supplies from WHO and HNI.

123 health facilities with functional laboratory units received different laboratory equipment and reagents from WHO, HNI and other NGOs that provided for the reading of more than 500,000 blood smear slides.

The infectious diseases ward in Mirwais hospital (Kandahar City) received substantial support from WHO.

b. Training activities:

Due to security reasons and logistical constraints in the northern and northeastern regions, special emphasis in training was given to community based health workers.

Different categories of health workers (MOPH and NGOs) in the eight regions were trained on preventive, curative, and promotive aspects of malaria control:

201 male and female doctors attended 5 days malaria workshops.

116 laboratory technicians received 2-3 weeks refresher training courses.

87 nurses and MLHW attended 5 days malaria workshops.

236 community health worker received training on simple malaria management, bednets methodology, and health education.

Health education component accompanied the distribution of bednets. Health messages were broad casted through BBC drama series. Local “Radio Sharia" in Kandahar and Jalalabad cities continued its health education program to increase awareness for personal protection, thanks to HNI and malaria committee members.

WHO provided the necessary teaching-learning materials and paid the travel cost and per diem for the participants and facilitators. WHO national health coordinators in the eight sub-offices facilitated some of these training activities. HNI established and fully run the training centre in the southern region. HNI trainers facilitated all the bednets and microscopy training in areas where it is operational and trained trainers in the remaining parts. MOPH provided training venues and participated with facilitators in some training courses particularly those for doctors’ training.

3.6 Drug resistance

P. falciparum infection:

Afghanistan:

Studies conducted by Healthnet International (1999 [1]) reported 67% P. falciparum resistance to chloroquine in the eastern part of the country, with 11% RII-RIII resistance. All cases were successfully treated with sulfadoxine-pyrimethamine (SP).

Pakistan:

Chloroquine resistance has also been reported (reference?) as widespread in Pakistan.

SP resistance has been reported in western Pakistan (19952,3), ranging from 4 to 25% in. SP resistant infections were successfully treated with chloroquine.

In Iran, SP resistance has been reported from Hormozgan, Sistan-Baluchestan and Kerman (tropical part)[2].

P.vivax infection:

Afghanistan & Pakistan

There are no reports of chloroquine resistant plasmodium vivax in these countries

3.7 Vectors

The vectors of Afghanistan have a strong preference for animals (zoophiliy) and tend to rest in-doors (endophiliy). Another major feature of Afghan vectors is that they breed in a wide variety of habitats. A. superpictus is the most common and most important malaria vector in Afghanistan[3]. It is found in the northern and southern parts of the Hindukush and it is widely spread throughout the country. Breeds in pools on the side of mountain streams and at times of rice fields as well.

Table 9: Major vectors of Afghanistan: breeding places, biting and resting habits 14,15

|1Vector |Breeding places |Biting habits |Resting habits |

|Anopheles stephensi |Urban: |Adult prefers domestic animals |Indoors after feeding |

| |Man-made habitats eg.cisterns, |(zoophilic), |(endophilic) |

| |wells, gutters etc., fresh water |Humans indoors and out doors | |

| |even when polluted |(endophagic and exophagic) | |

| |Rural: | | |

| |Grassy pools and alongside rivers| | |

|An. Culcifaces |Irrigation ditches, rice fields, |Zoophilic, endophagic and |Mainly endophilic |

| |swamp pools, wells, borrow pits, |exophagic when biting humans | |

| |edges of streams, in sunlit or | | |

| |partially shaded habitats | | |

|An. Superpictus |Prefers flowing waters, such as |Zoophilic, endophagic and |Endophilic |

| |shallow water over rocky streams,|exophagic | |

| |pools in rivers, muddy hill | | |

| |streams and where vegetation may | | |

| |be present | | |

|An. Pulcherrimus |Weedy irrigation channels, |Zoophilic |Mainly endophilic |

| |marshes, clean stagnant water |Endophagic and exophagic | |

| |with or without vegetation, slow | | |

| |moving streams, ditches, rice | | |

| |fields | | |

3.8 Insecticide resistance and use

No recent insecticide resistance data are available.

An.stephensi and An.culcifaces were reported as highly resistant to DDT and dieldrin in 1978 16.

An.superpictus and An.pulcherrimus are also resistant to DDT 17

Deltermethrin SC and Lambdacyhalothrin CS are effective for residual spraying of canvas tents, plastic sheeting shetlers, and bed nets.

Permethrine has been used successfully for the treatment of chadors and etofenprox is likely to be a safe and effective option to permethrin for this type of application.

3.9 Impact of the complex emergency

Pre-1980s Afghanistan had an effective malaria control programme, the main control tool being house-spraying with DDT and malathion. These programmes broke down in the 1980s due to the general decrease in emphasis on eradication as a goal but also as a result of the war. This together with the concomittant breakdown in the country’s public health system, population displacement, poverty and the return of infected refugees from Pakistan resulted in malaria becoming a major health problem.

3.9.1 Refugees

3.9.1.1 Malaria in Northern Pakistan

Malaria became a major problem when 3 million non-immune refugees migrated to Pakistan and settled in 250 camps which were often sited on marginal waterlogged land highly suited to malaria transmission. A health care system was established by UNHCR and the Pakistani government, HealthNet International (HNI) provided technical support in malaria control. At the peak of the malaria epidemic in 1991, 148,000 cases were recorded. By 1995, this had fallen to 36,000 cases, mainly as a result of vector control and quality clinical services.

3.9.1.2 Malaria in Iran 15

Malaria risk exists in Iran from March to November in the provinces of Sistan-Baluchestan and Hormozgan, the southern parts of the provinces of governorates of Fars, Kohgiluych-Boyar, Lorestan, and Chahar Mahal-Bakhtiari, and the north of Khuzestan. This indicates that most of the Afghan refugee camps in Iran were situated in malarious areas.

Refugees returning from the malarious camps in Pakistan and from Iran may carry malaria parasites, causing increased infections rates in the vectors of Afghanistan, hence resulting in increased prevalence of clinical malaria in their non-immune neighbours.

3.9.2 IDPs

Non-immune IDPs from the non-malarious areas to areas of higher risk. In 1999 there was a movement of people from the Shomali valley and central highlands, which due to altitude are unlikely to support malaria transmission. Many of these people moved to Northern and Northeastern Afghanistan, data is not available from these areas, however many of them are low lying and likely to be malarious.

Outbreaks have been reported from the north of the country, in Faryab (22% P.falciparum prevalence), Heart, Baghlan and Kundus. No details of numbers affected or control measures are known 14.

3.10 Epidemics

3.10.1 Potential

There is a potential for increase in vectorial capacity through change in climatic conditions. Eastern Afghanistan is prone to malaria outbreaks especially when conditions remain mild and humid during late summer and where medical services are inadequate. Eastern Afghanistan is particularly prone whilst the health system is under redevelopment. Epidemics are most likely to occur during October and November, when P.falciparum is more prevalent.

Major risk factors include:

1. Population movement

There is a potential for epidemics due to the movements of people in two forms.

❑ The influx of non-immune population (such as from the central highlands) into the malarious areas of the north (Faryab and Samangan provinces), the northeast (the whole region), the east (Nangahar, Laghman and parts of Kunar province), the south (Helmand and Kandahar provinces), the west (parts of Farah province, Shinand and Torghundi districts in Heart province).

❑ Introduction of a number of infected individuals into a malaria-free area. This was clearly demonstrated in Badghis province outbreak in 1999 that claimed 8 lives and also in Yakawlang outbreak in September 2000 that claimed 15 lives. It is believed that displaced people from the neighboring Faryab province introduced the P. falciparum to Qalai Nao of Badghis province, while merchants from Yakawlang district who used to travel to Baghlan and Saripul provinces are thought to have introduced the parasite to those remote malaria-free villages.

2. Sudden increase in vectorial capacity as a result of unusual weather

Many parts of the country were stricken by drought and witnessed prolonged periods of abnormal warm weather during the past two years. Despite the lack of metrological facilities in current Afghanistan, people interviewed in the central highlands have confirmed this phenomenon. Unusual/unseasonal metrological conditions are believed to have increased vector capacity and subsequent malaria transmission in the Yakawlang epidemic (2,400 meter).

3. Drug resistance

The spread of chloroquine resistance due to widespread practices of self-medication and non-compliance with treatment regimes is now widespread.

3.10.2 Recent epidemics 14

In September 1999 there was a malaria outbreak in Nazian Eastern Afghanistan, the population of the areas is 8,500 and up to 15% of the population were reported as having confirmed P.falciparum malaria. No deaths were recorded and the outbreak was controlled. In the same month there was a P.falciparum malaria outbreak in Qalai Nao of Badghis province. Out of 293 cases, 8 deaths were recorded.

In November 1999 there was another malaria outbreak in Narang in Kunar Province. The population of this area is 23,000 and the prevalence of P.falciparum was reported as over 30%. Two deaths were reported and the outbreak was controlled.

Other outbreaks have been reported from the north of the country, in Faryab (22% P.falciparum prevalence), Heart, Baghlan and Kundus. No details of numbers affected or control measures are known.

In September 2000 there was a P.falciparum malaria outbreak in Yakawlang district of Bamyan province with 15 deaths reported.

3.10.3 Surveillance systems

In the Eastern region NGO clinics are requested to report any outbreaks of malaria (i.e. health facility data showing higher incidence rates than would normally be expected for the season). HealthNet International conduct 6 monthly prevalence surveys in Eastern Zone. Crosschecking of microscopically diagnosed cases in the Malaria Reference Centers (MRC) in the eastern and southern regions gives high degree of confidence in the officially reported cases from these two regions.

In the 4th quarter of 1999, WHO received substantial support from the regional office for surveillance activities. The plan is to strengthen the capacities of the network of MRCs in the country.

A register book for malaria microscopy in Pashto and Dari, with gender, age, species, and location breakdown is currently under printing by WHO and would be distributed to all health facilities with microscopy service. The aim is to standardize the reporting system of this activity nation-wide.

3.10.4 Preparedness

WHO stocks contingency supplies of antimalarial drugs in the eight regions for use in emergency situations. The supplies and the travel costs for the teams in any region (whether mobilised by HNI or MOPH) are usually covered by WHO (for example, the outbreaks in Kunar, Badghis, Faryab and Yakawlang). UNICEF also provided antimalarials during the Yakawlang outbreak.

3.11 Recent control measures Eastern Region 12

In the Eastern Zone HNI conduct malaria control activities in conjunction with the MOPH. Activities presently being undertaken include:

• clinical management

• laboratory training and monitoring

• distribution of insecticide treated mosquito nets

• cattle sponging

• urban larval control programme in Jalalabad

• use of Gambusia fish in and around Jalalabad, particularly for rice fields

• training of medical officers in malaria control and management

• prevalence surveys for surveillance

• malaria outbreak control

• health education

3.11.1 Clinical Management

A new WHO recommended protocol for the treatment of uncomplicated and severe malaria cases has been developed for the emergency (see annex).

3.11.1.1 Improved diagnostic and clinical services

WHO supports the Malaria Reference Centre and its network of clinics in each of the 8 regions. HNI also participate in the supports of three of these centres in the eastern region (Jalalabad), the southern region (Kandahar) and the northern region (Mazar-e-sharif).

3.11.2 Personal protection

3.11.2.1 Repellent

Repellents – Mosbar a repellent soap is now being imported from Zimbabwe. It is being repackaged by HIN/MCP, the new packaging was designed in dari and pashtu and Mosbar was renamed Afiat (health and security). Local trials measuring acceptability and effectiveness are still to be held.

3.11.2.2 Insecticide treated mosquito nets (ITNs)

a. Insecticide impregnated bed nets:

Promotion of a net using culture in Afghanistan is steadily gaining grounds, thanks to the tireless efforts exerted over the past six years.

Generation of revolving fund that ensures the sustainability of the program is well maintained through cost sharing approach.

During 98-1999, WHO and HNI managed to provide 200,000 nets (100,000 each) along with the insecticide necessary for impregnation. The NGO AMI donated 13,000 nets and the private sector in Kandahar City produced 6721 locally made nets.

The revenue from the sale of 37,000 WHO nets last year at a subsidized rate of $ 4/net is used for procurement of more nets and insecticide this year.

During 1999, the program was able to distribute 62,507 impregnated nets and re-impregnate 39,601 nets distributed during the past years. The distribution took place through more than 150 outlets that included MoPH and NGOs health facilities, mosques, CHW, and mobile teams. (See attached distribution map).

3.11.2.2.1 Health education and ITNs

Nets are only sold after purchasers have attended pre-sale education sessions. The dipping process is conducted on site, usually by the purchaser himself to emphasise the importance of the insecticide. Posters in clinics, and calendars given away free with each purchase depict key messages. Publicity for the programme is conveyed by the BBC Pashtu service and through Mullahs from the mosques.

3.11.2.2.2 Sales strategy

Three methods are used: -

• Highly subsidies ITNs – areas which have been identified as having particularly high malaria prevalences are being supplied with nets for which a nominal fee only is charged. Subsidised nets are being distributed at the rate of one net for every three people in the family and the distribution is heavily supervised to guard against the leakage of heavily subsidised nets into other areas.

• Partially subsidised nets – HNI in negotiation with the Taliban authorities arrived at a selling price of $4 for ITNs, which amounts to around 25% subsidy. Ninety-eight distribution outlets have been created in Eastern Zone, including Community Health Workers (CHWs), health centres, private outlets and recently mullahs in mosques. Monitoring of all implementors is ongoing. HNI is also distributing nets on behalf of WHO.

• Private Sector Initiative for net sales and Insecticides – it is felt that for ITNs to be fully sustainable in the future, distribution must be taken over by the private sector or at non-subsidised prices by other agencies.

For the private sector initiative a branded pre-treated net called MUHAFIZ (protector or guard in both Dari and Pashtu) has been developed. Similarly a re-treatment kit ZAMIN (guarantor or guardian) has also been developed. The re-treatment kit is also being used for cattle sponging.

Private sector sales are being targeted in areas where HNI/MCP does not normally work and in Khost, Paktia Province, where the population is of a comparatively high socio-economic status. A price of $4.80 was set under agreement with MOPH Jalalabad for Muhafiz, which covers the majority of net production costs. The agreed price of 15 rupees for the re-treatment kits represents a 50% subsidy. However, as implementation with respect to re-treatment is still a problem it was felt that full cost recovery was not appropriate.

3.11.2.2.3 Promotion of ITNs

• Health education programme

• Sermons from mosques

• Local newspapers – information about malaria, also lists ITN outlets throughout Eastern Zone. There are also advertisements for Muhafiz Nets and the Zamin insecticide treatments.

Radio – as distribution of newspapers is limited radio is employed to reach a wider audience. Interviews with HNI/MCP staff are conducted and there is a short advertisement emphasizing the dangers of malaria.

Local production of nets

The NGO IAM is producing nets in Kabul using imported pre cut pieces from Thailand. They have offered the nets to HNI/MCP to distribute.

3.11.3. Urban control in Jalalabad City

Control measures include

• Canal cleaning, removal of weeds and filling in of ponds

• Gambusiae fish

• Larviciding with Abate (temephos)

• Weekly monitoring

Collaboration on this project includes, HNI/MCP, MOPH MRC, WHO, WFP.

3.11.3.1 Gambusia fish project

This programme is being run by MOPH MRC with HNI/MCP giving technical assistance and WHO providing funding

3.11.4 Community based malaria control

• Health education on how to recognise symptoms of malaria

• Education on where mosquitoes are likely to breed

• Education on recognition of mosquito larva

• Dealing with breeding sites by clearing out weeds etc and filling in ponds

• Training on use of Gambusia fish and larvicides

No evaluation of this project has yet been performed but the response by the communities has been positive.

3.11.5 Cattle sponging

This technique was developed in refugee camps in NorthWest Frontier Province Pakistan but is now also being employed in Nangahar Province, Eastern Afghanistan.

Due to the high cost of house spraying as a malaria control technique alternative methods of mass protection were sought. As the mosquitoes of South Asia are highly zoophilic and prefer biting cattle to humans a campaign of cattle sponging with insecticide was undertaken. The deltamethrin insecticide employed was effective in controlling mosquitoes, ticks and lice. As ticks are a major problem in Afghanistan/Pakistan the insecticide improves cattle health and productivity and hence people are generally willing to pay for the insecticide and treat their own cattle

At present in Eastern Zone cattle sponging is offered free in repatriation zones (Sorkh Rod, Qargaie and Kama) but elsewhere an element of cost recovery is included. In Behsud and Shinwar cattle sponging is being offered at full cost recovery.

• Private sector kits for self treating cattle at home

• Bring cattle for treatment at a slightly higher cost

The NGO MADERA has plans to start a similar project in Laghman District

3.12 Recent control measures in other regions

❑ Since 1998, WHO and MOPH have designated the central, western, southern and southeastern regions for distribution of ITNs.

❑ The urban malaria control programme in Kabul (the central region) which has been ongoing for the last three years includes ITNs, larviciding, and a Gambusia fish programme. It is a tripartite project between WHO, IMPD, and WFP.

❑ HNI is currently operational in the southern and northern zones, however, security poses a problem in northeastern zone i.e., Baghlan, Kunduz, Takhar and Badakhshan provinces. WHO managed to get ITNs across the frontline to northeastern province in 1999. In August 2000, WHO arranged for an HNI trainer to conduct the training of MRC and NGO staff in Badakhshan, which is the capital of the northern alliance opposition.

3.13 Cultural factors

3.13.1 Perceptions of malaria

Limited knowledge of malaria in the Afghan population leads to late treatment seeking behaviour and lack of personal protection.

3.13.2 Traditional practises

Mullahs – religious men, well respected to whom many people initially go with health problems

Greek doctors – use traditional herbal and other food based remedies

Ziarats – holy shrines to which many people go when looking for cures for their illnesses rituals here include the wearing of amulets.

3.13.3 Treatment seeking behaviour

A study conducted in two health clinics in Jalalabad found that 23% and 19% of people attending for malaria tests had already taken chloroquine 18.

There is a general belief among Afghan women that anitmalarials, particularly chloroquine, cause miscarriage. Pregnant women usually refrain from taking it during pregnancy.

3.14 Recommended prophylaxis and stand-by treatment for international staff 19

Chemoprophylaxis:

Afghanistan Season: May – November in areas below 1500 m

Recommended: chloroquine 300mg weekly in combination with proguanil 200 mg daily. Alternatively, chloroquine can be taken as 600mg per week, divided over 6 daily doses, in combination with daily proguanil.

Iran Limited risk–exclusively in the benign (P. vivax) form–exists in some areas north of the Zagros mountains and in western and south-western regions during the summer months. Malaria risk in the malignant (P. falciparum) form exists from March through November in rural areas of the provinces of Hormozgan, Kerman (tropical part) and Sistan-Baluchestan.

Recommended in P. falciparum risk areas: chloroquine 300mg weekly in combination with proguanil 200 mg daily. Alternatively, chloroquine can be taken as 600mg per week, divided over 6 daily doses, in combination with daily proguanil.

Pakistan Season: year-round in areas below 2000 m

Recommended: chloroquine 300mg weekly in combination with proguanil 200 mg daily. Alternatively, chloroquine can be taken as 600mg per week, divided over 6 daily doses, in combination with daily proguanil.

Alternative chemoprophylaxis options: mefloquine (250mg weekly) or doxycycline (100 mg daily)

Chloroquine and mefloquine should be started at least a week before arrival or before the beginning of the transmission season; proguanil and doxycycline should be started the day before. The drugs should be continued for 4 weeks after departure from the endemic area.

Stand-by emergency treatment:

Chemoprophylaxis can not offer 100% protection. In case of a breakthrough, suspected malaria infections can be treated with quinine, given as 8 mg base/kg bodyweight 3 times daily for 7 days. Urgent medical attention should be sought to confirm the diagnosis and adjust the treatment, and to exclude other causes of fever.

4. HEALTH SERVICES

4.1 Statistics

Table 10: Health services statistics 1,2

|Children immunized against measles % 1997 |58 |

|Health expenditures around 1995 | |

|Total % of GDP |- |

|Public sector % of GDP |- |

|Public sector % of total |- |

|% of routine EPI vaccines funded by government 1995-1997 |0 |

Table 10 indicates that the government in 1995 had no input into the funding of EPI vaccines - however, it should be noted that in 1995 the civil struggle for power was at its height. Figures are not available for government expenditure on health. A good indicator of the low level of health services (or utilisation of them) is that only 58% of children were immunized against measles in 1997. (See Annex for Health facility, Infrastructure and Capacity as of 1999, source WHO/EMRO)

4.2 Health policy in relation to malaria

Prior to the war MOPH ran regional malaria control programmes throughout the country. There is presently no National Malaria Control Programme and therefore no national recommended treatment schedules for malaria. HNI and WHO support the Malaria Reference Centre in Jalalabad and its network of clinics in the Eastern Region. Fees are being introduced to cover programme costs (at least partially). The distinction between public and private sector provision is becoming increasingly blurred. Yet standards in the private sector are highly variable. HNI and MOPH hope to improve standards by offering training and certification to staff working in private sector clinics. MOPH is being encouraged to adopt a regulatory role and to monitor quality in the private sector.

4.3 Coverage by health facilities

Much of the health network within the country has been destroyed. A UNHCR returnee monitoring survey found that only 58% of those interviewed said that there were health facilities within a reasonable distance from their place of return.

4.4 Access to health services by women

The gender policies of the Taliban have the aim of segregation of men and women. Strict controls on the movement of women outside the home have been introduced so that women are always separated from male strangers or are escorted by male relatives.

The effect that these policies have on the access to health care by women varies dramatically in different regions of the country and also between urban and rural areas.

Taliban policies have not had much effect on the daily life of rural women. Traditions in the rural areas are very much as they always have been. Many rural women support the policies of the Taliban and are comfortable with the regime. Security has been improved, bandit leaders who terrorized the countryside have disappeared.

The problem has been for the educated women from cities such as Kabul, Herat, Kandahar and Jalalabad. Policies of the Taliban are much more strictly enforced in the urban centres, especially in Kabul. Because of restrictions on their movements, women often forego medical treatment. Attendance at pre-natal and post-natal clinics, for instance, has dropped and Afghanistan currently has one of the worst maternal and child mortality rates in the world.

4.5 Health manpower, training and institutions

During 1999 different categories of health workers (MOPH and NGOs) were trained on preventive, curative, and promotive aspects of malaria control as follows:

201 male and female doctors attended 5 day malaria workshops

116 laboratory technicians received 2-3 week refresher training courses

87 nurses and MLHW attended 5 day malaria workshops

236 CHWs received training on uncomplicated malaria management, bednets methodology and health education.

WHO provided the necessary teaching materials and funding, together with national health coordinators to facilitate some of the training. HNI established and ran the training centre in the southern region. HNI facilitated training on bednet technology, and microscopy for malaria, in areas where they are operational, together with training of trainers for other areas. MOPH provided training venues and participated in facilitation of some of the training courses.

4.6 Health systems

The policy of the Taliban was to continue the tradition in Afghanistan of free medical consultations.

However, several cost sharing initiatives have been instigated recently, many by NGOs.

4.7 Health partners

NGOs

HealthNet International

Austrian Relief Committee

SCA

IIRO

Private sector

A multitude of pharmacies are found on urban streets. Many private laboratories perform malaria parasite tests to varying standards. There is no regulation of the private sector.

5. Miscellaneous

5.1 Suppliers

5.1.1 Nets

Siamdutch Mosquito Netting Co. Ltd

15, Sukhumvit Soi

33, Bangkok 10110, Thailand

Tel: +66 2 2585621/2599404

Fax: +66 2 2595084

E-mail: mosquito@ksc8.

5.1.2 Insecticides

AgrEvo Pakistan Ltd

P.O. Box 4962

Karachi 74000

Tel: 00 92 21 506 0721

Fax: 00 92 21 506 0638

5.1.3 Drugs

Local suppliers, WHO

5.1.4 Laboratory reagents

Local Suppliers in Pakistan

5.2 Key contacts

5.2.1 Agencies

Malaria Project Co-ordinator

HealthNet International

11A, Circular Lane,

Box 889

University Town

Peshawar

Pakistan

5.2.2 MOPH

Dr Malang Muslem

President of the Institute of Malaria and Parasitic Diseases (IMPD)

Ministry of Public Health

Kabul

Afghanistan

5.3 Key references

5.3.1 Reviews

Rowland M. ‘Review of published literature on malaria control in complex emergencies’ WHO RBM/EHA expert group meeting on malaria control in complex emergencies 1-2 December 1998, Geneva.

6. PAKISTAN 20

As stated above more than 3 million refugees from Afghanistan fled to Pakistan, they lived (and many still do) mainly in camps along the border as shown in Map 3. Many of these non-immune refugees rapidly succumbed to malaria in camps that were situated on marginal, malarious land in Pakistan 21 In the early 1990s over 150 000 cases of malaria were being diagnosed and treated each year by the medical services which were under the supervision of UNHCR and the Government of Pakistan. Twenty five per cent of cases were due to P.falciparum and 75% were due to P.vivax 22.

A great deal of research into the development of methods of personal protection and vector control, appropriate to crisis and post-crisis situations, has been carried out by HealthNet International in these camp populations.

6.1 Tent spraying during the acute phase of the emergency

One of the major findings from the studies in North West Frontier Province (NWFP) Paksitan was that treating the inner surface of double-sheeted tents with permethrin or deltamethrin provides a surface toxic to insects that lasts for a least a year 23. Treating single-sheeted tents is not as effective as the life of the insecticide is reduced especially at high altitudes 24. Efficacies of 66% 25 and 85% 26 have been found against P.falciparum and 69% against P.vivax 26. Plastic sheeting should be discouraged as it cannot be effectively treated with insecticide.

Tent spraying is analogous to house spraying in that, because mosquitoes rest on the inner surface of tents after feeding, it is not a method of personal protection but rather, produces a mass reduction of the mosquito population. This has important applications in refugee and IDP populations, firstly in, reducing the transportation of infections to unaffected areas. Secondly, by reducing the spread of infection from refugees and IDPs into the local population, they may also help in controlling the spread of drug resistance.

6.2 Insecticide treated mosquito nets (ITNs)

ITNs have been found to confer a 60-70% protective effect against P.vivax and P.falciaprum malaria in the Afghan refugee camps of NWFP 27,28. In complex emergencies health and malaria control systems often break down to such an extent that personal protection may be the only option. ITNs do however, require a change in behaviour in communities which don't have experience of using nets. The experience with Afghan refugees is promising, they had no history of ITN usage, yet the protective effect of 60-70% was still achieved.

6.3 Permethrin treated clothing or bedding

Some of the drawbacks to the use of ITNs in complex emergency situations are that not everyone can afford them and importation and supply may pose problems. In answer to this problem the possibility of impregnating clothing or bedding was investigated in NWFP Afghan refugees. Here chaddars, which are a cloth or veil worn by women which covers the head and upper body and doubles as a sheet at night when it is used by both sexes, were impregnated with permethrin. The odds of having a P.falciparum or P.vivax episode of malaria were reduced by 64% in children aged 0-10 years and by 38% in refugees aged ................
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