PREVALENCE OF MALARIA IN DISTRICT LOWER DIR,

PAKISTAN

BY

UMAR ZADA

SHAHID KHAN

AND

SHAHZAIB KHAN

MSc Zoology (2 Years)

Department of Zoology

University of Malakand

Session 2021-2023
PREVALENCE OF MALARIA IN DISTRICT LOWER DIR,
PAKISTAN

BY

UMAR ZADA

SHAHID KHAN

AND

SHAHZAIB KHAN
Thesis submitted to the Department of Zoology,

University of Malakand for the partial fulfillment of the

requirements for the degree of

MSc(2-Years)

IN

ZOOLOGY

DEPARTMENT OF ZOOLOGY

UNIVERSITY OF MALAKAND

SESSION 2021-2023
 DECLARATION

We declare that the thesis “PREVALENCE OF MALARIA IN DISTRICT LOWER

DIR, PAKISTAN” is our original work and has never been previously Presented

or published or written by another person nor any materials which up to

substantial extent has been accepted for the award of any degree at any other
university before and that all the information sources, we have used or quoted
have been indicated and acknowledged by means of complete reference.”

UMAR ZADA

SHAHID KHAN

AND

SHAHZAIB KHAN

i
 DEDICATION

THIS WORK IS DEDICATED TO

Our Parents and respected teachers

We dedicated this piece of work to our loving and responsible parents. We are
extremely thankful to our loving parents, respected teachers, brothers, and
sisters. We believe in their most honest and innocent prayers which are a
constant source of strength and inspiration to us that play a main role in our
life. May Allah give us strength to serve them to our best, AMEEN.

UMAR ZADA

SHAHID KHAN

AND

SHAHZAIB KHAN

ii
 ACKNOWLEDGMENTS

We have no words to express our deepest sense of gratitude to Al-Mighty ALLAH, who give
us mental and physical strength that enabled us to complete this difficult task in time. It was
sheer boon of ALLAH that we got loving parents, inspiring and talented teachers and
friends who provide us the intellectual guidance, moral support and all-round help for the
fulfillment of our work. We offer my humblest thanks for the core of my heart to Prophet
Muhammad (S. A. W) who is forever torch of guidance and knowledge for humanity. We
wish to pay most sincere regards to our supervisor Dr. Mohammad Attaullah Assistant
Professor department of Zoology and Dr. Ikram Ilahi Chairman, Department of Zoology
University of Malakand for valuable suggestions, heartiest cooperation and encouragement
without which this work would never be complete.

And finally, we are thankful to our family as they were our constant energy source in this
journey, most importantly my parents, brothers and sisters. We couldn’t have done it without
their immense support and encouragement.

UMAR ZADA

SHAHID KHAN

AND

SHAHZAIB KHAN

iii
 List of Contents

DECLARATION ....................................................................................................................... i

DEDICATION .......................................................................................................................... ii

ACKNOWLEDGMENTS ....................................................................................................... iii

LIST OF TABLES .................................................................................................................. vii

LIST OF FIGURES ................................................................................................................ vii

ABSTRACT ........................................................................................................................... viii

CHAPTER 1 .............................................................................................................................1

INTRODUCTION....................................................................................................................1

1.1 Malaria: .......................................................................................................................1

1.2 History of malaria: ......................................................................................................1

1.3 Causes of malaria and pathogenicity:..........................................................................2

1.4 Transmission of malaria: .............................................................................................3

1.5 The clinical signs and symptoms: ...............................................................................4

1.6 Malaria vector control: ................................................................................................5

1.7 Life cycle of malaria parasite: .....................................................................................6

1.7.1 Schizogony-in man: ..............................................................................................6

1.7.1.1 Pre-erythrocyticschizogony (7-9 days): ...........................................................6

1.7.1.2 Erythrocyticschizogony (48-72 hours): ............................................................6

1.7.1.3 Secondary erythrocyticschizogony: .................................................................7

1.7.2 Sporogony in Mosquito: ......................................................................................7

1.8 Diagnosis: ....................................................................................................................8

1.9 Epidemiology: .............................................................................................................9

1.10 Risk factors of malaria ..............................................................................................11

1.11 Treatment ..................................................................................................................11

1.12 Resistance ..................................................................................................................12

1.13 Prevention: ................................................................................................................12

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 1.14 Malaria in Pakistan: ...................................................................................................13

1.15 Aims and Objectives: ................................................................................................13

CHAPTER 2 ...........................................................................................................................14

LITERATURE REVIEW .....................................................................................................14

CHAPTER 3 ...........................................................................................................................18

MATERIALS AND METHODS ..........................................................................................18

3.1 Study area: .................................................................................................................18

3.2 History of study area: ................................................................................................18

3.2.1 Location: ............................................................................................................18

3.2.2 Area: ...................................................................................................................18

3.2.3 Population: .........................................................................................................18

3.2.4 Climate: ..............................................................................................................18

3.3 Rain fall: ....................................................................................................................18

3.4 Blood collection: .......................................................................................................20

3.5 Rapid diagnostic test: ................................................................................................20

3.5.1 Test procedure:...................................................................................................20

3.6 Microscopy: ...............................................................................................................20

3.7 Data analysis: ............................................................................................................20

3.7.1 Species-wise malaria patients: ...........................................................................21

3.7.2 Month-wise malaria patients: .............................................................................21

3.7.3 Gender-wise malaria patients:............................................................................21

3.7.4 Age-wise malaria patients: .................................................................................21

CHAPTER 4 ...........................................................................................................................22

RESULTS ...............................................................................................................................22

4.1 Species-wise prevalence of malaria: .........................................................................22

4.2 Gender-wise prevalence of malaria: ..........................................................................23

4.3 Month-wise prevalence of malaria: ...........................................................................24

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 4.4 Age-wise prevalence of malaria: ...............................................................................25

CHAPTER 5 ...........................................................................................................................26

DISCUSSION .........................................................................................................................26

5.1 Conclusion:................................................................................................................27

5.2 Recommendations .....................................................................................................27

REFERENCES .......................................................................................................................29

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 LIST OF TABLES

Table 4. 1: Plasmodium species-wise prevalence of malaria in District Dir Lower, Khyber-

Pakhtunkhwa, Pakistan from June 2023 to November 2023. .................................................. 22
Table 4. 2: Gender-wise prevalence of malaria in District Dir Lower, Pakistan from June
2023 to November 2023........................................................................................................... 23
Table 4. 3: Month-wise prevalence of malaria in District Dir Lower, Khyber-Pakhtunkhwa,
Pakistan from June 2023 to November 2023. .......................................................................... 24
Table 4. 4: Prevalence of malaria in different age groups among population of District Dir
Lower, Khyber-Pakhtunkhwa, Pakistan from June 2023 to November 2023. ........................ 25

LIST OF FIGURES

Figure 1. 1: Clinical sign and symptoms of malaria .................................................................. 5

Figure 1. 2: Life cycle of malaria parasite ................................................................................. 8
Figure 3. 1: Map of District Dir Lower.................................................................................... 19
Figure 4. 1: Species-wise prevalence of malaria in District Dir Lower year 2023 .................. 22
Figure 4. 2: Gender-wise prevalence of malaria in District Dir Lower, year 2023. ................ 23
Figure 4. 3: Month-wise prevalence of malaria in District Dir Lower, year 2023. ................. 24
Figure 4. 4: Age-wise prevalence of malaria in District Dir Lower, year 2023. ..................... 25

vii
 ABSTRACT

Malaria is caused by a protozoan parasite of the genus Plasmodium and is moderately

endemic in Pakistan. This study was conducted from June 2023 to November 2023 with the

aim of determining the prevalence of human malaria in District Dir Lower, Khyber-

Pakhtunkhwa, Pakistan. The data was collected from District Head Quarter (DHQ) Hospital,

Timergara and Tehsil Head Quarter (THQ) Hospital Chakdara, District Dir Lower. A total of

12747 patients were examined, and 621 were positive for malarial parasites, giving an overall

prevalence of 4.8%. The species of Plasmodium detected were Plasmodium vivax, with a

percentage of 617 (99.35%), and Plasmodium falciparum, with a percentage of 4 (0.65%).

Mixed species were not observed. The prevalence of Plasmodium vivax in males was 388

(62.5%) and in females was 229 (36.9%) While that of Plasmodium falciparum in males was

1 (0.16%) and females was 3 (0.48%), respectively. Prevalence of Plasmodium vivax was

highest in subjects aged 16-30 years, while that of Plasmodium falciparum was highest in

those aged 31-45 years. Plasmodium vivax was most prevalent in the month of September,

while Plasmodium falciparum was prevalent in the month of August. The male population

and people aged above 16 years were more infected, and Plasmodium vivax was the

predominant species in the study area.

Keywords: Malaria, Protozoa, Dir Lower, Prevalence, Plasmodium vivax, Plasmodium

falciparum, Parasite.

viii
 CHAPTER 1

1 INTRODUCTION

1.1 Malaria:
One of the most serious health issues on a global scale, malaria disproportionately

affects those residing in tropical and subtropical regions. According to Soomro et al. (2009),

it is responsible for more than one million fatalities annually and has immense significance in

underdeveloped nations. Parasitic protozoan of the genus Plasmodium infects humans and

other animals via mosquito-borne infectious diseases like malaria (Ferry, 2009). The malaria-

causing parasite, Plasmodium, is a single-celled organism. Malaria may infect over a hundred

different species of birds, animals, people, and more. Under a microscope, Plasmodium

species that infect people appear differently (Collins, 2012). One of the world's challenges is

malaria. In addition to killing millions of people every year, it makes the world's most fertile

areas uninhabitable. Worldwide, malaria infections occur between 200 and 300 million times

every year, resulting in half a million fatalities (WHO, 2014). Plasmodium causes malaria,

which is transmitted by certain types of vectors. The parasites that cause malaria are

classified into five species: malariae, falciparum, vivax, ovale, and knowlesi. The two most

prevalent species of malaria in Pakistan are Plasmodium vivax and Plasmodium falciparum.

An estimated 1.5–2.7 million people die each year from these 300–500 million cases.

According to the World Health Organization (2014), 627,000 people lost their lives to

malaria in 2013.

1.2 History of malaria:

An imperial edict by Emperor Huang Ti somewhere about 2700 BC contains the first

known account of malaria. There was a discussion of fever and enlarged spleen in the Nei

Ching, the Chinese medical canon, as indications of malaria. As a sign of illness, many

1
Egyptian mummies have swollen spleens. Malaria probably killed Alexander the Great in 323

BC.

In 1848, VirchoPiktured described pigmented bodies in the blood of malarial patients.

Charles Louis Laveran (1845–1922), a French Army surgeon, was the first person to identify

malarial parasites in humans in 1880. For the first time, this discovery attracted little

attention, but in 1907, he received the Nobel Prize for his discovery. Camillo Golgi (1843–

1916) deduced that different malarial parasites, malariae and vivax, caused different malaria

fevers. Falciparum was identified by two Italian malariologists, Marchifava and Bignami,

and they also associated it with the most dangerous and severe form of malaria. The fourth

species, ovale, was not discovered until 1922.

The work of J. Wager von Jauregg in curing syphilis using malaria led to his 1972 Nobel

Prize. The initial step in treating syphilis was inoculating patients with fever-inducing

malarial germs. To treat malaria, the patient was administered quinine after three or four

fever cycles. Up until the mid-1990s, this was the standard. Scientists began to suspect

mosquitoes as malaria transmitters in the middle to late 1800s. One such scientist was Patrick

Manson (1844–1922), a Scottish doctor. Ronald Ross (1857–1922) was a doctor in the Indian

Medical Service. Between 1895 and 1898, he worked out the life cycle of the malaria

parasite. He also showed that infected mosquitoes could transmit the malaria parasite. In

1948, Shortt and Graham described the exo-erythrocytic stages of Human malaria parasites

(Dhiman et al., 2008).

1.3 Causes of malaria and pathogenicity:

The parasite Plasmodium causes malaria, an infectious illness. Humans may get

malaria from one of four different parasite types. Plasmodium falciparum, which was

2
responsible for the deaths of countless people, remains a major health concern today. The

disease it produces is called malignant tertian malaria. Its incubation period is 9-14 days.

Plasmodium vivax, the most common malarial parasite, causes benign tertian malaria. Its

incubation period is 12-17 days. Plasmodium ovale is the least common species of human

parasite and is also the least pathogenic. Most Africans have been shown to be susceptible to

Plasmodium ovale. Its incubation period is 18-40 days.

Plasmodium vivax and Plasmodium falciparum are two species that are endemic to Pakistan.

Plasmodium vivax, a kind of malaria parasite, has reduced virulence compared to other

strains. However, its eradication via the interruption of transmission between people and

mosquitoes is notably challenging due to its ability to persist in a latent state inside the human

liver for six months. On a monthly or annual basis (WHO, 2008).

1.4 Transmission of malaria:

The bites of infected female Anopheles mosquitoes, when they are feeding, are the vectors

that spread the infectious illness known as malaria. Among the 300 species of mosquitoes,

around 100 are known to transmit illnesses to humans. The female of the species feeds on

blood to nurture her eggs, which is how malaria is spread. Thus, malaria is transmitted by

female Anopheles mosquitoes. In many areas, mosquitoes that bite at night are the ones

carrying the malaria parasite. Between the hours of 12 AM and 4 PM, you may find older

insects that are more likely to be infected. However, the Anopheles mosquito often bites

during the hours of dark and light.

A wide variety of watery places, including pools and shady ponds, as well as hoof

prints and tire tracks, are ideal breeding grounds for Anopheles mosquitoes. Water that is not

too contaminated is preferred by them. In certain areas, artificial containers like tanks or pots

serve as ideal breeding grounds. The life cycle begins with the female laying eggs on the

water, which continues through the stages of larvae and pupae. At last, the egg will hatch into

3
a mosquito. Depending on the humidity and temperature, the process might take anywhere

from seven to sixteen days. The life cycle accelerates with increasing humidity and warmth.

According to the malaria control handbook and the humanitarian manual, mosquitoes often

refrain from biting during the 22–23 days it takes for eggs to hatch.

1.5 The clinical signs and symptoms:

Typically, 8–25 days after the bite, signs of malarial sickness will begin. Malaria symptoms

include high body temperature, chills, weakness, headache, back pain, nausea, vomiting,

diarrhea, chills, and sometimes coughing. Malaria is often misdiagnosed as the flu, dengue

fever, typhoid, blood poisoning, viral hemorrhagic fevers, or meningitis because of the

similarity in their symptoms. Confusion, vertigo, disorientation, and comas are among

neurologic complaints that might manifest at times (Nadjm et al., 2012).

Another illness has the same signs and symptoms. To make a correct diagnosis, further

observations are required. Only by carefully analyzing the patient's blood-stained blood film

under a microscope can a malaria diagnosis be made (Bruce-Chwatt, 1980).

4
 Figure 1. 1: Clinical sign and symptoms of malaria
Source: https://www.saisivahospital.com/malaria-fever-in-children-symptoms-treatment-
and-prevention-in-the-rainy-winter/ (Date accessed: 25-12-23).

1.6 Malaria vector control:

The Anopheles mosquito transmits human malaria. It is the population of the vector that

determines the disease's prevalence. As a result, reducing the infection prevalence requires

the control assessment of the vector. There are several methods to control the vector. These

are the most crucial.

(1) The direct use of insecticides (commonly used Dichlorodiphenyltrichloroethane (DDT).

Marathon and deltamethrin.

(2) Use of mosquito repellent.

(G) Use of insecticide-treated net (ITN).

5
(4) Mosquito larval source reduction.

(5) Indoor residual spraying of households with insecticides (IRS).

1.7 Life cycle of malaria parasite:

They consist of two cycles.

(a) Schizogony or asexual life cycle (in man).

(b) Sporogony or sexual life cycle (in mosquitoes).

1.7.1 Schizogony-in man:

This cycle in man is divided into three phases:

(a) Pre-erythrocyticschizogony (in liver cells).

(b) Erythrocyticschizogony (in RBCs)

(c) Secondary erythrocyticschizogony (in liver cells).

1.7.1.1 Pre-erythrocyticschizogony (7-9 days):

This phase of schizogony occurs in liver cells. After the bite of an Anopheles mosquito,

sporozoite is introduced into man's skin. It enters the circulation and reaches the liver. In the

liver, it enters the parenchymal cells. Heterosporozoite undergoes the process of growth and

multiplication and forms a large schizont (pre-erythrocyticschizont). This schizont contains

thousands of tiny particles. For 7-9 days, liver cells containing merozoites rupture and

liberate them in the circulation. Here, the phase of pre-erythrocyticschizogony ends (Anwar,

2001).

1.7.1.2 Erythrocyticschizogony (48-72 hours):

This process of schizogonyoccurs in RBCs. After entering the circulation, merozoite enters

the fresh RBC. Here, it matures into small "trophozoites.” When the cells divide, and the

cytoplasm begins to separate, it is called an immature "Schizont." Later on, when the parasite

has reached the stage at which it is fully segmented and when the "Merozoite" is just

liberated by disruption of RBCs, it is called mature "Schizont". Now RBCs contain a large

6
number of "merozoites", and when merozoites" are liberated into circulation, some

"merozoites" again attack the fresh. RBCand the cycle of "erythrocyteschizogony" repeats.

The duration of this phase in "Plasmodium vivax,” "Plasmodium ovale,” and "Plasmodium

falciparum" is 48 hours. "Plasmodium malariae,” it is 72 hours (Anwar 2001).

1.7.1.3 Secondary erythrocyticschizogony:

This phase of schizogony occurs in liver cells. When "pre-erythrocyticschizogony"

ruptures and "merozoites" are liberated into the circulation, some of the "merozoites" again

invade the liver cells and the cycle of "pre-erythrocyticschizogony" is repeated. This cycle is

seen in "Plasmodium vivax", "Plasmodium ovale", and Plasmodium malaria".

1.7.2 Sporogony in Mosquito:

The sporogony or sexual cycle occurs almost entirely in the "Anopheles mosquito".

Certain "merozoites", instead of repeating the asexual cycle (schizogony), become

gametocytes; some are male, and some are female. They circulate in the peripheral blood.

When a mosquito bites a man and sucks the blood, gametocytes are taken up by the mosquito.

Other asexual forms are destroyed in the gut of mosquitoes; only gametocytes survive. From

one male gametocyte (also called a microgametocyte), 5-8 thread-like filamentous structures

are developed by the process called ex-flagellation. Now, they are called microgametocytes.

The female or macro gametocyte has, meanwhile, undergone nuclear division and has

transformed into a female gamete or macrogamete. This is an unfertilized ovum. Which

attracts the active microgamete, one of which penetrates it, and fertilization occurs. After this,

the fertilized ovum, or zygote, is capable of slow movement and, hence, is known as

"ookinete," penetrates the cell lining of the mosquito's gut until it reaches the outer limiting

membrane. At this site, a cyst wall becomes stationary. This round form is called "oocyst.”

Inside the cyst wall, the nucleus of the zygote

7
Figure 1. 2: Life cycle of malaria parasite
Source: https://www.cdc.gov/malaria/about/biology/index.html

Divided repeatedly, and finally, thousands of minute threads-like structures are formed.

Which are called "sporozoites." The oocysts now rupture, and "sporozoites" are released into

the haemocele (body cavity), whose circulation carries them to all parts of the mosquito's

body. Some of them go to the salivary glands. When it bites a man, the salivary fluid

containing the "sporozoites" passes into the slim wound and finally reaches the circulation,

and the cycle repeats. The sexual cycle in mosquitoes requires about 8–18 days for its

completion (Anwar, 2001).

1.8 Diagnosis:

Currently, diagnosing malaria with Giemsa stain microscopy is considered the most

accurate method. But you'll need a skilled microscope and some fancy lab gear for it.

Consequently, the quality of the results varies widely (Adeyi et al., 2010). The threshold for

diagnosis of malaria by microscopy is 4–20 parasites/L under ideal conditions and 50–100

parasites/L under field conditions (Conteh et al., 2010).

Rapid diagnostic tests (RDTs) have been identified as game-changers for malaria diagnosis in

regions where laboratory access is not readily available. It has the advantage of a point-of-

care test that can inform immediate clinical decision-making in the field. RDT is based on
8
detecting malaria antigens in a subject's blood by immune chromatographic methods using

monoclonal antibodies directed against parasite antigens. Target antigens are abundant in

both the asexual and sexual stages of the parasite. The sensitivity of RDT is based on parasite

density. RDT sensitivity decreases if the parasite density of Plasmodium falciparum is less

than 100/µL and that of Plasmodium vivax is less than 5,000/µL (Hutton et al., 2009).

In Thailand, a study showed that parasite density sensitivity was 100 per cent above 500/µL,

and 83 per cent of densities were less than this (Conteh et al., 2010). In general, the HRP2-

aldolase system was less sensitive to non-Plasmodium falciparum testing, whereas the PLDH

system was more sensitive to Plasmodium vivax infection. False positives can also be a

problem with a few tests, as RDTs can cross-react with rheumatoid factor and heterophile

antibodies. However, some improvements have been made for rheumatoid factor in recent

tests (Bojang et al., 2011). Currently, molecular techniques like DNA probes and polymerase

chain reaction (PCR) are usually utilized for research rather than clinical purposes. They can

be used to identify submicroscopic infections. Although RDTs and microscopy are available,

many individuals are diagnosed based on clinical symptoms alone and presumptively treated

for malaria without any formal testing. The World Health Organization does not recommend

this strategy because many of the clinical symptoms of malaria overlap with other infections,

leading to the overuse of anti-malarial drugs and under diagnosis of other potentially serious

diseases (Wilson et al., 2011). Therefore, confirmatory testing is a recommended measure.

1.9 Epidemiology:

Assuming that current malaria interventions were still having the desired effect, the

World Health Organization (2008) set the attainable goal of reducing the disease's impact in

high-transmission areas and, ideally, eliminating it in low-transmission regions. A

commitment at all levels, a strengthened health system, and the creation of new intervention

tools are all necessary for the objectives to be achieved. Still, programmes must be

9
continuously re-oriented based on the illness load. According to Mendis K. et al., (2009), the

programmes is undergoing a reorientation that starts with "control" and continues through

"consolidation" (a high and stable malaria transmission setup), "pre-elimination," and finally

"elimination" with the goal of preventing re-introduction. There are 99 nations where malaria

is a problem; 32 of them are working to eliminate the disease (Feachmen et al., 2010).

"Interrupting local mosquito-born" was the previous definition of malaria eradication, while

"reducing the disease burden to a level at which it is no longer a public health problem" is the

current definition of malaria control. Ones of malaria that have been transposed, while ones

that have been imported, will still happen. A degree of ongoing intervention is necessary

(WHO 2008).

Malaria in Pakistan is severe, has a short life span, and can be overcome by a sequence of

active and passive interference. The initiation of the cold season in November terminated the

spread of malaria (Toby Leslie et al., 2009). Most of the infections are due to plasmodium

vivax, although some are due to plasmodium falciparum, which is increasing and accounts for

about 35–40% of cases (Khan et al., 2004). Pakistan and Punjab have come through severe

and distressing malaria epidemics in the twentieth century. Since the 1980s, malaria has been

at a lower level as compared to the rest of Pakistan and India, where it is at its peak

(Klinkenberg et al., 2004). According to Kakar et al. (2010), 37% of malaria cases occur in

the Federally Administered Tribal Areas (FATA), districts, and agencies bordering

Afghanistan and Iran. Malaria is also common in Baluchistan, Sindh, and Khyber

Pakhtunkhwa.

Another risk factor for malaria is pregnancy. Studies have shown that pregnant women in

malaria-endemic regions are more likely to get the disease, and pregnant women have greater

rates of sickness incidence and severity compared to non-pregnant women (Brabin, 1983;

McGregor, 1983; Kochur et al., 1998). This risk factor is due to the prompt suppression of

10
cell-mediated immunity (Kochar et al., 1998; Bouyou-Akotet et al., 2003; Beck et al., 2001).

Cerebral malaria, maternal anemia, intrauterine growth retardation, preterm labour, preterm

delivery, and abortion all contribute to the high risk of morbidity and death (Kocher et al.,

1998; Sullivan et al., 1999). Medicines that are used as anti-malarials also induce

complications. Most of the infections are due to plasmodium vivax, but complications are

mostly seen in plasmodium falciparum in Pakistan (Menedez, 1995). Placental malaria leads

to pregnancy-related complications such as low birth weight in neonates, premature birth, and

abortion (Kocharet et al., 1998).

1.10 Risk factors of malaria

Infants and young children, the elderly, and travelers from malaria-free regions are at

a higher risk of severe illness. Aspects that quantify the degree of physiological breakdown,

loss of function in organ systems, or even mortality; the real risk of malaria in the region

being visited; the duration of stay in the location; and the season in which malaria is

transmitted. Lack of acquired immunity is the leading cause of mortality in children under the

age of five. Additionally, the body's natural defences are especially weak in pregnant women.

While a woman is pregnant, her mechanisms are less active (WHO, 2004). Refugees,

displaced people, non-immune travelers, and laborers entering endemic regions are other

high-risk populations. The potential for malaria transmission differs substantially across

different locations within a given region. Although the likelihood of malaria is much lower

than 1000 meters, hot, tropical regions may see seasonal outbreaks as high as 3000 meters

(WHO 2009). Agricultural operations may also impact areas where mosquitoes breed.

Swamps lose their larval breeding grounds as they dry out.

1.11 Treatment

The treatment of malaria encompasses a range of efficacious pharmaceutical

interventions; nonetheless, it is essential to prioritize prompt diagnosis and expeditious

11
initiation of therapy. The primary cause of mortality in children suffering from severe malaria

is attributed to delayed access to medical facilities. Certain strains of malaria have the

potential to result in fatality within a matter of days or even hours subsequent to their

manifestation. However, prompt treatment often offers a high likelihood of successful

eradication of the disease. Individuals who manage to live may nonetheless have enduring

health complications. A shorter period between diagnosis and treatment would save lives for

individuals living in rural regions without access to healthcare, which is why more mobile

workers and health outposts are, needed (World Health Organization, 2018)

1.12 Resistance

Drug resistance is a main hazard in malaria treatment. Why does resistance occur?

The exact reason is still unclear, but certain factors account for it: huge therapeutic

medications, plasmodium involved, and genetic alteration by these medicines. Plasmodium

vivax is resistant to chloroquine. Plasmodium falciparum is resistant to proguanil and

pyrimethamine. Chloroquine-resistant strains are mostly present in Southeast Asia, the

Amazon region, and Africa (Kager and Wetesteyn., 1996).

1.13 Prevention:

The Anopheles mosquito mostly bites at sunrise and early evening (Fradin 1998). People

sleeping outsides must have pyrethroid-impregnated nets (Mbaye et al., 2012 and Gambel et

al., 2007). The World Health Organization also suggests using nets (Breman, 2009). Long

pyrethroid insecticide-treated bed nets can also be used (Petersen, 2004).

Wear long sleeves, pants, loose-fitting garments, and socks, and apply Permethrin or DEET

to clothing after dark (Uedelhoven 2006, and Snodgrass, 1992). For four weeks after leaving

a malaria region, patients should continue taking mefloquine, a suppressive prophylactic that

attacks the malaria parasite at its red blood cell stage (Paredes and Santos-Preciado 2006).

12
1.14 Malaria in Pakistan:

Malaria infections have been documented in Pakistan, with the transmission of the

disease often occurring during the monsoon season in July and August. It is predicted that

there are around 0.05 billion clinical cases of malaria each year in Pakistan (Donnelly et al.,

1999). Medication, mosquito extermination, and bite avoidance are all part of malaria

preventive strategies. The density of both the human population and the Anopheles mosquito

population determines whether malaria is present in a certain location (Sabot et al., 2010).

1.15 Aims and Objectives:

i. To evaluate the species of malarial parasite in District Dir Lower, Pakistan.

ii. To find out prevalence of malaria in Dir Lower according to different age and gender.

iii. To study month-wise prevalence of malaria in District Dir Lower.

iv. To find out tehsil-wise rate of malaria patients in District Dir Lower

13
 CHAPTER 2

2 LITERATURE REVIEW

Khan et al. (2019) conducted a parasitological survey to assess the prevalence of malaria at

DHQ hospital Batkhela and THQ hospital Dargai District Malakand Khyber Pakhtunkhwa,

Pakistan. A total of 1123 suspected patients' blood samples were collected, and both the thick

and thin blood smears were made and then stained with Giemsa stain and examined under a

microscope. Out of these, 300 (26.7%) tested positive for malaria. Of the positive cases, 296

(98.6%) were Plasmodium vivax and 4 (1.3%) were Plasmodium falciparum. No mixed-

species infection and no cases of Plasmodium ovale and Plasmodium malariae were found.

Malaria was high in those aged <16, followed by those in the age group 33–50, and the least

in the 51–80 age group. Males were more infected than females.

Awan et al. (2012) conducted a parasitological survey to assess the prevalence of malaria

among the primary school children in the rural areas of Bannu District, Khyber Pakhtunkhwa,

Pakistan. A total of 556 blood smears were collected from the 11 schools’ children between

the ages of 5 and 15. Thick and thin blood smears were made and stained with Giemsa stain;

examine them microscopically. Out of these, 17 (13.5%) were found to be positive, and the

screening of the positive slides showed that Plasmodium vivax (2.69%) was more common

than Plasmodium falciparum, and no mixed cases were found. According to this, the

prevalence of malaria was equal to 0.03% in both males and females.

Khan et al. (2021) conducted a parasitological survey to assess the incidence and infection

related to plasmodium in the peoples of District Dir Lower, Khyber Pakhtunkhwa, Pakistan.

A total of 1439 blood samples were taken by the finger-pricked process of all individuals in

the study sample, from which thin and thick blood smears were prepared on the same slides.

Used methyl alcohol for the fixation of thin smears. A Giemsa stain of 10% was used for the

staining of blood film. All the slides were examined carefully under a microscope with a

14
100X objective. Out of these, 232 (16.12%) were positive for malaria. Which was found

higher in age group 16–30, 76 (18.22%), while fewer cases were founded in age group 31–45

years, 45 (14.46%). Males 174 (18.45%) were found to be more infected than females 58

(11.69%). In the month-wise study, August 49 (18.42%) and July 46 (18.11%) were founded

with the highest prevalence. while the lowest prevalence was noted on April 10 (12.98%).

Muhammad and Husain (2003) conducted a survey to assess the prevalence of malaria in the

general population of District Bunner Khyber Pakhtunkhwa, Pakistan. From the month of

March to August 2001. A total of 1020 blood samples were collected and stained with

Giemsa stain after making thick and thin blood smears. Out of these 70 (6.08%) slides, one

was found to be positive. Out of these positive slides, 59 (5.78%) were infected with

Plasmodium vivax, and 11 (1.08%) were infected with Plasmodium falciparum. The

prevalence rate was found to be higher in adults than children, and the prevalence rate was

also higher in males than females. The rate was lower in March. Record high in the month of

August and lower in March.

Khattak et al. (2011) conducted a malariaometric population survey using blood samples

collected from 801 febrile patients of all ages in four provinces and the capital city of

Islamabad. Microscopically confirmed plasmodium-positive blood samples were confirmed

by polymerase chain reaction. Confirmed parasite-positive samples were subjected to

species-specific PCR capable of detecting four species of human malaria. Out of the 707

PCR-positive samples, 128 (18%) were Plasmodium falciparum, 536 (76%) were

Plasmodium vivax, and 43 (6%) were mixed; Plasmodium ovale and Plasmodium malariae

were not detected. The prevalence of Plasmodium vivax ranged from 2.4% in Punjab

Province to 10.8% in Sindh Province, and the prevalence of Plasmodium falciparum ranged

from 0.1% in Islamabad to 3.8% in Baluchistan.

15
Tasawar et al. (2003) conducted a survey to determine the prevalence of malaria in District

Multan, Punjab, Pakistan. A total of 252 blood samples were collected and stained with

Giemsa stain after making thin and thick blood smears. Out of these, 8 (3.17%) were infected

with Plasmodium vivax, and 3 (3.19%) were infected with Plasmodium falciparam.

According to this, the prevalence of malaria was higher in males (5.55%) as compared to

females (3.17%). Among the positive cases, the prevalence of malaria in children was higher

than in adults.

Khan et al. (2013) conducted a survey to find out the prevalence of malaria among neonates

in both urban and rural areas of District Kohat, Khyber-Pakhtunkhwa, Pakistan, from. July

2011 to May 2012. All of these children's blood was not transfused previously, and their ages

ranged from 1 to 30 days. A total of 615 blood samples were collected, and thick and thin

blood smears were stained with Giemsa stain and examined microscopically. Among the total

samples, males were 357 (58.04%) and females were 258 (41.95%). Only the male neonates

were observed to have neonatal malaria (3.36%), while no positive case was reported in

female neonates.

Shahid and Khan (2012) conducted a study to determine the variation in frequency of

Plasmodium vivax and Plasmodium falciparum malarial parasites in different seasons of the

year in Khyber Teaching Hospital, Peshawar, Khyber-Pakhtunkhwa, Pakistan. A total of 441

patients were included in the study by preparing thin and thick blood smears that were then

stained with Giemsa stain. According to this, out of the total 441 diagnosed malaria cases,

134 (32.6%) were presented in the autumn season: Plasmodium vivax (33.58%) and

Plasmodium falciparum (66.42%, in the winter (37%), Plasmodium. vivax (32.4%) and

67.7%. 76 (18.49%) in spring, Plasmodium vivax 99.41%, Plasmodium falciparum 6.6%, and

164 (39.90%) in the summer and winter seasons, while Plasmodium vivax reaches its peak in

the spring and summer seasons.

16
Sahar et al. (2012) conducted a survey to find out the prevalence of the Plasmodium

falciparum malaria parasite in District Muzaffer Bagh, Punjab, Pakistan, from November

2008 to October 2010. A total of 10082 suspected cases were collected, stained with Giemsa

stain, made into thin and thick blood smears, and then examined under a microscope. Out of

the total, 208 (2.07%) were examined for Plasmodium falciparum, and according to this

adult, it was the most affected class. In males, the Plasmodium falciparum infection was

higher than in females.

Junejo et al. (2012) conducted survey research to assess the prevalence of malaria in

children's hospital, Chandka Medical College Larkana, from January 2008 to December

2008. A total of 200 blood samples were collected and examined microscopically by making

thin and thick blood smears and then stained with Giemsa stain. Among the total 200 cases,

117 (58.5%) were males and 83 (41.5%) were females. According to this, the prevalence of

malaria was founded at 73 (36.5%), Plasmodium falciparum was seen in the majority 43

(58.9%) of cases as compared to Plasmodium vivax 30 (41.9%), and there were no cases

recorded of Plasmodium malariae or Plasmodium ovale.

Yasinzae and Kakarasulmankhel (2009) conducted a survey to investigate the incidence of

malaria infection in central Baluchistan, Pakistan from July 2004 to June 2006. A total of

3709 blood samples were collected, made into thin and thick blood smears, stained with

Giemsa stain, and examined under a microscope. The overall incidence of slide positivity was

noted at 39.9%, while Plasmodium vivax was observed at the highest (86.2%) as compared to

that of Plasmodium falciparum. According to this survey, the infection of males was 75.5%

higher than that of and female was 24.4%, and no cases of other species were observed. The

seasonal variation was also noted, with the highest (91.4%) infection of Plasmodium vivax in

December and the lowest (71.4%) in January, while infection of Plasmodium falciparum was

highest (28.5%) in January and lowest (8.5%) in December.

17
 CHAPTER 3

3 MATERIALS AND METHODS

3.1 Study area:

Data was collected from District Head Quarter Hospital, Timergara, and Tehsil Head Quarter

Hospital, Chakdara District Dir Lower from June 2023 to November 2023.

3.2 History of study area:

3.2.1 Location:

District Dir Lower, located in the north of Khyber-Pakhtunkhwa province of Pakistan, is one

of the most important regions, both historically and culturally.

3.2.2 Area:

The total area of District Dir Lower is 1583 sq. km.

3.2.3 Population:

According to the 2023 census, the population of District Dir Lower was 1,650,183.

3.2.4 Climate:

District Dir Lower is situated in the temperate zone; the summer season is moderate and

warm; June and July are the hottest months, with an average temperature of 340C; but

January and February are the coldest months.

3.3 Rain fall:

Rainfall varies throughout the year. Most of the rainfall occurs during the summer season; the

annual rainfall is about 32.2 inches. The rainfall is, however, less than the summer rainfall.

18
 Figure 3. 1: Map of District Dir Lower
Source:https://dailytimes.com.pk/303578/rickettsial-claims-nine-lives-in-lower-dir/amp/

Patient selection:

Total blood samples (N=12747) were randomly collected from June 2023 to November 2023

in the laboratories of DHQ Hospital Timergara and THQ Hospital Chakdara District, Dir

Lower. Blood films were collected from patients coming to these hospitals who complained

of malaria symptoms like fever, chills, shivering or a history suggestive of malaria. All these

patients were referred to laboratories for the collection of peripheral blood to be investigated

for malaria. A pro forma of the data report was also filled in the laboratory during field work,

in which information about patient name, sex, age, and locality, presence or absence of

malaria parasites, and type of parasites were mentioned. The patients having malaria, i.e.,

showing malaria parasites in their blood, were divided into five groups: 1-5 years old,

children (6-15 years of age), adults (16-30 years of age), 31-45 years of age, and above 45

years of age. A clinical pathologist was asked to count, examine, and report RDT stripes and

fill out the data sheet.

19
3.4 Blood collection:

The blood was collected from adult and child peripheral blood veins through a syringe, but in

the case of neonates and infants under six (6) months, the puncture was made on the plate

underneath the palm of the foot.

3.5 Rapid diagnostic test:

Malaria rapid diagnostic test (RDTs) assist in the diagnosis of malaria by providing evidence

of the presence of malaria parasites in human blood. RDTs are an alternative to diagnosis

based on clinical grounds or microscopy, particularly where good-quality microscopy

services cannot be provided.

3.5.1 Test procedure:

1) Ensure specimens and test kits are brought to room temperature before testing.

2) Open the foil-wrapped pouch and remove the cassette.

3) Using a pipette or dropper, transfer the whole blood specimen to the blood collection

tube.

4) Read the results in ten minutes once the colored lines have appeared.

3.6 Microscopy:

Blood samples were examined through microscopy. Fingertip of each patient was cleaned

with methylated spirit and pricked with disposable lancet. Both thick and thin blood smears

were prepared on the same slide, fixed with methyl alcohol, stained with Giemsa stain, and

examined under 100X oil immersion objective.

3.7 Data analysis:

The data of all patients was collected from the above-mentioned hospitals in year 2023. The

data was analyzed on the basis of the following parameters:

20
3.7.1 Species-wise malaria patients:

The patients were divided into groups based on month-wise, and the percentage of each

group was calculated.

3.7.2 Month-wise malaria patients:

The patients were divided into groups on the basis of month-wise, and the percentage of each

group was calculated.

3.7.3 Gender-wise malaria patients:

The patients were divided into two groups based on their sex, i.e., male and female. The

percentage of male and female groups was also calculated.

3.7.4 Age-wise malaria patients:

The patients were divided into different groups based on their age, and the percentage of each

group was calculated.

21
 CHAPTER 4

4 RESULTS

4.1 Species-wise prevalence of malaria:

A total of 12747 blood samples were tested during the present study period in which 621

were positive. In these positive cases 617 (99.4%) cases were due to Plasmodium vivax and 4

(0.6%) cases were due to Plasmodium falciparum .And no mixed cases were found.

Table 4. 1: Plasmodium species-wise prevalence of malaria in District Dir Lower, Khyber-

Pakhtunkhwa, Pakistan from June 2023 to November 2023.

Species Male n (%) Female n (%) Total positive

slides n (%)

Plasmodium vivax 388 (62.5%) 229 (36.9%) 617 (99.4%)

Plasmodium falciparum 1 (0.16%) 3 (0.5%) 4 (0.6%)

Mix species 0 (0.0%) 0 (0.0%) 0 (0.0%)

700
Number of positive malaria cases

600
Male
500
400
Female
300
200
Total
100
0
P.vivax P.falciparum Mix species
Plasmodium species

Figure 4. 1: Species-wise prevalence of malaria in District Dir Lower year 2023

22
4.2 Gender-wise prevalence of malaria:

Of the total positive cases, 389 (62.9%) males and 232 (37.4%) females were positive for

malaria parasites.

Table 4. 2: Gender-wise prevalence of malaria in District Dir Lower, Pakistan from June

2023 to November 2023.

Gender Total slides Plasmodium Plasmodium Mix species Total positive

n (%) falciparum n (%) vivax n (%) n (%) slides n (%)

Male 6507 (51.1%) 1 (0.16%) 388 (62.5%) 0 (0.0%) 389 (62.6%)

Female 6240 (48.9%) 3 (0.5%) 229 (36.9%) 0 (0.0%) 232 (37.4%)

7000
Total slides

6000
P.falciparum
Number of malaria cases

5000
P.vivax
4000

3000 Mix species

2000 Total positive

slides
1000

0
Male Female
Gender

Figure 4. 2: Gender-wise prevalence of malaria in District Dir Lower, year 2023.

23
4.3 Month-wise prevalence of malaria:

Prevalence of malaria cases was highest in the month of September 140 (22.5%) and lowest

in the month of June 65 (10.5%).

Table 4. 3: Month-wise prevalence of malaria in District Dir Lower, Khyber-Pakhtunkhwa,

Pakistan from June 2023 to November 2023.

Months Total slides Plasmodium Plasmodium Mix Total positive

(%) falciparum vivax (%) species slides (%)

(%) (%)

June 1305 (10.23%) 0 (0.0%) 65 (10.5%) 0 (0.0%) 65 (10.5%)

July 1810 (14.2%) 0 (0.0%) 70 (11.3%) 0 (0.0%) 70 (11.3%)

August 3157 (24.8%) 3 (0.5%) 136 (21.9%) 0 (0.0%) 139 (22.4%)

September 2565 (20.1%) 1 (0.16%) 139 (22.4%) 0 (0.0%) 140 (22.5%)

October 2275 (17.8%) 0 (0.0%) 135 (21.8%) 0 (0.0%) 135 (21.8%)

November 1635 (12.8%) 0 (0.0%) 72 (11.6%) 0 (0.0%) 72 (11.6%)

3500
Number of malaria cases per month

3000 Total slides

2500
P.falciparu
2000 m
P.vivax
1500

1000 Mix species

500
Total +ive
0 slides
June July August September October November
Months

Figure 4. 3: Month-wise prevalence of malaria in District Dir Lower, year 2023.

24
4.4 Age-wise prevalence of malaria:

According to age, most of the people were infected in their age group 16-30 years 277

(44.6%) and lowest in the people their age group 1-5 years 10 (1.6%).

Table 4. 4: Prevalence of malaria in different age groups among population of District Dir

Lower, Khyber-Pakhtunkhwa, Pakistan from June 2023 to November 2023.

Age(year Total slides n Plasmodium Plasmodium Mix species Total positive

s) (%) falciparum n (%) vivax n (%) n (%) slides n (%)

1-5 657 (5.6%) 0 (0.0%) 10 (1.6%) 0 (0.0%) 10 (1.6%)

6-15 3216 (25.22%) 0 (0.0%) 142 (22.9% 0 (0.0%) 142 (22.9%)

16-30 4838 (37.9%) 2 (0.32%) 275 (44.3%) 0 (0.0%) 277 (44.6%)

31-45 2781 (21.81%) 2 (0.32%) 132 (21.6%) 0 (0.0%) 134 (21.7%)

Above 45 1255 (9.84%) 0 (0.0%) 58 (9.3%) 0 (0.0%) 58 (9.3%)

6000
Number of malaria cases in different age

Total slides
5000
P.falciparum
4000

P.vivax
groups

3000

2000 Mix species

1000 Total positive

slides
0
1 to 5 6 to 15 16 to 30 31 to 45 Above 45
Age groups (years)

Figure 4. 4: Age-wise prevalence of malaria in District Dir Lower, year 2023.

25
 CHAPTER 5

5 DISCUSSION

The present study was conducted in District Head Quarter Hospital Timergara and Tehsil

Head Quarter Hospital Chakdara District Dir Lower for a period of six months from June

2023 to November 2023. The data were analyzed using different parameters, according to

species-wise malaria patients, gender-wise malaria patients, month-wise malaria patients, and

age-wise occurrence of malaria.

In our result, the species-wise prevalence of Plasmodium vivax was recorded to be 617

(99.4%) and Plasmodium falciparum was recorded to be 4 (0.6%), and no mix species were

recorded during this study. Plasmodium vivax was recorded as the predominant species in the

study area. A high rate of plasmodium falciparum was also observed in other parts of the

country: 98% in Okara (Sarwat and Jahan, 2010), 90.4% in Muzafar abad (Jan and Zain,

2001), 60.5% in Multan (Yar et al., 1989), and 39% in south Punjab (Shehzadi et al., 2008).

A high rate of Plasmodium vivax was also observed in Kohlu at 58.9% (Yasinzai and

Kakarsuleimankheel, 2008) and 64.7% in Zia rats (Yasinzai and Kakarsuleimankheel, 2009).

Sex-wise prevalence showed that malaria was more common in males (388 (62.5%) than

females (229 (36.9%)) in this study. This higher prevalence in males may be because males

mostly go out and work in an open environment without covering their bodies. On the other

hand, due to social costumes, females are limited to home and cover themselves well, so they

are not exposed to mosquito bites in most cases. A study conducted by Irshad et al. (2013)

showed a similar higher prevalence of malaria in males (62.12%) than females (37.88%).

Males are the predominant victims in District Buner, Khyber-Pakhtunkhwa, Pakistan (Ahmad

et al., 2013).

26
In the current study, the data was collected from June 2023 to November 2023. The month-

wise distribution of malaria showed that the rate of prevalence was higher in the month of

September (22.54%) and lower in the month of June (10.5%). Our result differs from the

research study of Isabel Vigmo et al. (2010). The study found that 4 patients occurred in the

month of June, and 95 patients were reported in the month of September. These differences

are due to climatic and seasonal changes in different countries.

In our result, we find that different ages of people are affected at different instants in the

whole research duration. The highest rate of infection, 277 (44.6%), was recorded in people

aged 16–30 years, and the lowest was 10 (1.6%) in people aged 1–5 years. Previously, it has

been shown that malaria is more prevalent in age group of 21-30 years (42.65%) followed in

age 1-10 years (21.03%) (Khan et al., 2005).

5.1 Conclusion:

Malaria in District Dir Lower is caused by Plasmodium vivax and Plasmodium falciparum

with Plasmodium vivax being the most prevalent. The high rate of infection was found in the

month of September and while low rate was found in Males is more infected than females.

Furthermore, it was find out that male are more affected by malaria due to the involvement of

more frequent outdoor activities as compare to female. It is concluded that malaria is highly

prevalent in adult as compared to child and old aged people.

5.2 Recommendations
As we found Plasmodium vivax as the predominant species in our research area, it causes

much complication and many causes of morbidity and mortality. With anti-malaria drugs, the

disease can be controlled and treated, which can decrease the complication mortality rate of

the infection. Quinin, chloroquine, lumefantrine, Fansider, and Artemether are commonly

27
used in intra- malaria in Plasmodium vivax malaria, and Quinin or artemether are used in

Plasmodium falciparum malaria.

In the research area, poor sanitary conditions and stagnant water also increase the prevalence

of malaria. If the sanitary condition of this area improved at the Govt level as well as by the

public, NGOs also decrease and controlled the infection of malaria in District Dir Lower. The

oral can be use on standing water to reduce the publication of mosquito vectors, which

ultimately decreases the chances of malaria attacks.

The common people are not aware of the controlled and prophylactic treatment of the malaria

disease there, so they do not use mosquito nets, netted windows, mosquito repellent, indoor

spray, and other street cleaning roles. Due to these mistakes, the infected improved and

increase year over year rather than being controlled. If the general population, the research

area is awarded by the Govt and after the welfare of NGOs through the media, newspapers,

television, mass media, project training, and other teaching classes of teachers and other

religious scholars.

Due to the awareness of common people, the intensity of the disease can be decreased and

controlled. Many doctors used those drugs, to which they become resistant, so the disease

was not so well treated by these drugs. In the future, advanced and effective drugs should be

used by doctors to treat.

28
 REFERENCES

A Färnert, AP Arez, HA Babiker, HP Beck, A Benito, A Björkman, MC Bruce, DJ Conway,

KP Day, Lars Henning, O Mercereau-Puijalon, LC Ranford-Cartwright, JM Rubio, G

Snounou, D Walliker, J Zwetyenga, VE Do Rosario Transactions of the Royal Society

of Tropical Medicine and Hygiene Genotyping of Plasmodium falciparum infections

by PCR: a comparative multicentre study 95 (2), 225-232, (2001).

A.AKhattak, M.Venkatesan, L.Khatoon, A.Ouattara, L.JKenefic, M.F Nadeem, FNighat,

Salman A Malik, Christopher V Plowe Malaria Journal Prevalence and patterns of

antifolate and chloroquine drug resistance markers in Plasmodium vivax across

Pakistan12 (1), 1-9, (2013).

Adeyi, O., Fischer, S. E, &Guindi, M. Liver allograft pathology: approach to interpretation of

needle biopsies with clinicopathological correlation. Journal of clinical pathology,

63(1), 47-74 (2010).

Ann M Moormann, Amy D Sullivan, Rosemary A Rochford, Stephen W Chensue, Paul J

Bock, Thomas Nyirenda, Steven R MeshnickJournal of Infectious DiseasesMalaria

and pregnancy: placental cytokine expression and its relationship to intrauterine

growth retardation 180 (6), 1987-1993, (1999).

Anwar, Illustrated Medical Parasitology E D 1, 34. (2001).

Berman J G, Eradicating malaria. SciProg, 92, 1-38. (2009).

Bojang, K. A., Akor, F., Conteh, L., Webb, E., Bittaye, O., Conway, D. J., & Greenwood, B.

Two strategies for the delivery of IPTC in an area of seasonal malaria transmission in

the Gambia: a randomised controlled trial. PLoS Medicine, 8(2), e1000409. (2011).

29
Bruce-Chwatt, malaria study in new Africa. New caravans of the old Saharan. Lancet, vol,

903-904. (1980).

Carol Gamble, Paul J Ekwaru, Paul Garner, Feiko O TerKuilePLoS Medicine Insecticide-

treated nets for the prevention of malaria in pregnancy: a systematic review of

randomised controlled trials 4 (3), e107, (2007)

Clara Menendez Parasitology today Malaria during pregnancy: a priority area of malaria

research and control 11 (5), 178-183, (1995).

Collins EW. 2012. Plasmodium knowlesi a malaria parasite of monkeys and humans. Annual

Review of Entomology 57, 107-21, (2012).

Conteh, L., Sicuri, E., Manzi, F., Hutton, G., Obonyo, B., Tediosi, F., & Tanner, M. The cost-

effectiveness of intermittent preventive treatment for malaria in infants in Sub-

Saharan Africa. PLoS ONE, 5(6), e10313. (2010).

Dhiman, R.C., Pahawa, S., and Dosh. Climate change and Malaria in India: intyerplay

Cbetween temperature and Mosquitoes, Regional Health Forum, 12 (1), 27-31(2008).

DK Kochar, Shubhakaran, BL Kumawat, I Thanvi, A Joshi, SP Vyas QJM: monthly journal

of the Association of Physicians Ophthalmoscopic abnormalities in adults with

falciparum malaria. 91 (12), 845-852, (1998).

Eveline Klinkenberg, Wim van der Hoek, Felix P Amerasinghe ActatropicaA malaria risk

analysis in an irrigated area in Sri Lanka 89 (2), 215-225, (2004).

F Kakar, Z Akbarian, T Leslie, ML Mustafa, J Watson, Hans P van Egmond, MF Omar &J

Mofleh, An outbreak of hepatic veno-occlusive disease in Western Afghanistan

30
 associated with exposure to wheat flour contaminated with pyrrolizidine alkaloids.

Journal of toxicology, (2010).

Faulde M, Uedelhoven W, A new clothing impregnation method for personal protection

against ticks and biting insects. International Journal of Medical Microbialogy, 296,

Supply 40, 225-9 (2006).

Ferry FF "Chapter 332. Protozoal infections". Ferry’s Color Atlas and Text of Clinical.

(2009).

Fradin M S. Mosquitoes and mosquito repellents a clinician's guide. An Internal Medicin,

128, 931-40 (1998).

Franco-Parades C. Santos-Preciado J 1. (2006) Problem pathogens: prevention of malaria in

travelers. Lancet Infectious Disease. 6. 139-49 (2006).

GS Humphreys, I Merinopoulos, J Ahmed, CJM Whitty, TK Mutabingwa, CJ Sutherland,

RLHallettAntimicrobial agents and chemotherapy Amodiaquine and Artemether-

Lumefantrine Select Distinct Alleles of the Plasmodium falciparum mdr1 Gene in

Tanzanian Children Treated for Uncomplicated 51 (3), 991-997, (2007).

Hutton, C., Draganski, B., Ashburner, J., & Weiskopf, N. (2009). A comparison between

voxel-based cortical thickness and voxel-based morphometry in normal aging Neuro

image, 48(2), 371-380 (2009).

Irshad M, Ali R, Akbar S, Muhammad, Ahmad T. Occurrence of malaria in Khwazakhela

District Swat Pakistan, PSCI publications.; 2(1):26-28 (2013).

31
Jan, A. and T.Kiani. "Haematozoan parasites in Kashmiri refugees." Pakistan Journal

Medical Research 40(1) 10-12 (2001).

Junejo, A.A., Abbasi, A.K., Chand, H; and Abbasi, S., Malaria in children at children hospital

chandka Medical College Larkana. Medical chanel, 18 (1) 55-57. (2012).

K Bouyou-Akotet, Denisa E Ionete-Collard, Modeste Mabika-Manfoumbi, Eric Kendjo,

Pierre-Blaise Matsiegui, Elie Mavoungou & M. Kombila Malaria Journal volume.

Prevalence of Plasmodium falciparum infection in pregnant women in Gabon 2(1), 1-

7 (2003).

Khan A, Mekan SF, Abbas Z, Smego A. Concurrent malaria and enteric fever in Pakistan.

Singapore Medical Journal; 46 (11), 635, (2005).

Khan W. Rahman AV. Khan W.Shafiq S. Ihsan H, Khan K. Malaria prevalence in Malakand

District, the north westron region of Pakistan. Journal Pakistan Medical Association.

69 (946), (2019)

Khan, I, Mehmood, S.A, Khan, W, Ahmed, S, Zia, A, Khan, N, RADS Journal of Pharmacy

and Pharmaceutical Sciences. Malaria Malaria in the Population District Dir Lower

Khyber Pakhtunkhwa, Pakistan 9 (2), 106-110, (2021).

Khan, S.N., Ayaz, S., Ali L, Sobia, A., Sumaria, S., Shahzad, Z., Asim, M.K and Rashid, F.

Bunder of malaria infection among neonates in highly epidemic region of Khyber-

Pakhtunkhwa, Pakistan. International. Journal of Advancement Research and

Technology 2 (4), 84-92, (2013).

Mayor, S. WHO report shows progress in efforts to reduce malaria incidence. BMJ: British

Medical Journal, 337 (2008).

32
Mayor, S. WHO World Malaria Report 2015. Geneva, Switzerland: World Health

Organization. pp. 32-42. ISBN 978-92-4156483-0 (2014).

Mbaye A. Richardson K, Balajo B. Dunyo S. Shulman C, Miligan P. ET AL. A randomized,

placebo-controlled trail of intermittment preventive treatment with. Sulphadoxine

pyrimethamine in Gambian multigravida. Trop Med Int Health, 11, 992-1002

Medicine. Elsevier Health Sciences. p. 1159. ISBN 978-1-4160-4919-7 (2012).

Mendis, K., Rietveld, A., Warsame, M., Bosman, A., Greenwood, B., & Wernsdorfer, W. H.

From malaria control to eradication: The WHO perspective. Tropical Medicine &

International Health, 14(7), 802-809, (2009).

Muhammad, N., and Hussain, A. Prevalence of malaria in general population of District

Buner. Journal of Postgraduate Medical Institute 17 (1), (2003).

Nadjm B, Behrens RH. Malaria an update for physicians. Infectious Disease Clinics of North

Amierica, 26(2), 243-259, (2012).

Petersen E, Malaria chemoprophylaxis when we should use it and what are the options.

Expert Review of Anti-Infective Therapy 2 (1) 119, (2004).

Sabot O, Cohen JM, Hsiang MS, Kahn JG, Basu S, Tang L. Zheng B. Gao Q. Zou L.,

Tatarsky A, Aboobakar S, Usas J. Barrett SD, Cohen JL., Jamison DT. Feachem RG.

Costs and financial feasibility of malaria elimination. The Lancet, 376 (9752), 1604-

1615, (2010).

Sahar, T., Akhtar, T., Bilal, H., and Rana, M.S. Prevalence of plasmodium falciparium,

malaria parasite in Muzaffergarh district, Punjab-Pakistan; a two year study. Pakistan

journal of science 64 (1), (2012).

33
Shahid, J., and Khan, M.N. Seasonal variations of vivax and falciparium malaria:

Anobservation at a tertiary care hospital. Journal of Ayub Medical College

Abbottabad 24 (1), 93-95, (2012).

Soomro, F.R., Kakar, J.K., and pathan, G.M. Malarial Parasite: Slidespositivityrateat

Shikarpur District Sindh Pakistan. The Professional Medical Journal., 16(03), 373-

379, (2009).

Tasawar, Z.. Manan, F., and Bhutta, A. Prevalence of Human malaria at Multan, Pakistan,

Journal. Medical science. 3,123-126, (2003).

Tauseef Ahmad, Akbar Hussain, Suhaib Ahmad. Epidemiology of malaria in Lal Qilla.

International Journal of Scientific and Technology Research, 2(11):199-202 10 (2013)

Wilson, C. J., Rickwood, D. J., Bushnell, J. A., Caputi, P., & Thomas, S. J. (2011). The

effects of need for autonomy and preference for seeking help from informal sources

on emerging adults intentions to access mental health services for common mental

disorders and suicidal thoughts. Advances in Mental Health, 10(1), 29-38, (2011).

Yasinzai, M.L., Kakarasulmankhel, J.K. Incidence of human malaria infection in central

Balochistan., Pakistan., District Bolan. Biologia (Pakistan,) 55 (1&2), 43-50, (2009).

34