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THIS PROJECT WAS SUPPORTED BY THE DIRECTORATE OF MALARIA CONTROL AND SAVE THE CHILDREN, THROUGH GRANT FROM GLOBAL FUND TO FIGHT AGAINST AIDS, TB AND MALARIA
Title: Malaria Indicator Survey in 38 High Risk Districts of Pakistan- 2013-14
Institution: Pakistan Medical Research Council
Year of Publication: 2014
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Title: Malaria Indicator Survey in 38 High Risk Districts of Pakistan- 2013-14
Institution: Pakistan Medical Research Council
Year of Publication: 2014
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AUTHORS Dr. Muhammad Arif Munir Pakistan Medical Research Council Dr. Huma Qureshi Pakistan Medical Research Council Dr. Nauman Safdar Social and Health Inequalities Network
DATA ANALYSIS Syed Ejaz Alam Pakistan Medical Research Council
TECHNICAL ADVISORS Dr. Qutbuddin Kakar World Health Organization Mr. Naeem Durrani Merlin, Pakistan Dr. Muhammad Imran Save the Children Dr. Abdul Majeed Jaffar Directorate of Malaria Control
MAPPING HOTSPOTS Mrs. Farzana Naheed Social and Health Inequalities Network
EDITORIAL ASSISTANCE MR. MUHAMMAD ARIF NADEEM SAQIB Pakistan Medical Research Council
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TABLE OF CONTENTS
ACRONYMS AND ABBREVIATIONS ...... xviii FOREWORD ...... xx ACKNOWLEDGEMENTS ...... xxii EXECUTIVE SUMMARY ...... xxiv 1. INTRODUCTION ...... 1 GEOGRAPHY, CLIMATE AND DEMOGRAPHY ...... 1 1.1.1. Geography ...... 1 1.1.2. Climate ...... 1 1.1.3. Demography ...... 3 HEALTH CARE IN PAKISTAN ...... 4 1.2.1. Health Profile ...... 4 1.2.2. Health Systems ...... 5 MALARIA IN PAKISTAN ...... 7 1.3.1. Overview ...... 7 1.3.2. Malaria Vectors ...... 7 1.3.3. Malaria Burden ...... 8 1.3.4. Malaria Control Pakistan- Global Fund Support ...... 10 MALARIA CONTROL OBJECTIVES AND INDICATORS FOR GF SUPPORTED DISTRICTS ...... 11 1.4.1. Objectives...... 11 1.4.2. Indicators (GF Round 7 & 10) ...... 11 2. PAKISTAN MALARIA INDICATOR SURVEY ...... 15 2.1. RATIONALE OF MALARIA INDICATOR SURVEY...... 15 2.2. SURVEY OBJECTIVES ...... 15 2.3. ETHICAL APPROVAL AND CONSENT ...... 16 2.4. SURVEY METHODOLOGY ...... 17 2.4.1. Study Design and Approach ...... 17 2.4.2. Data Collection ...... 18 2.4.3. Data Management and Analysis ...... 23 3. HOUSEHOLD POPULATION AND CHARACTERISTICS ...... 25 3.1. HOUSEHOLDS ACCESSED AND RESPONSE ...... 25 3.2. HOUSEHOLD POPULATION BY SIZE, AGE AND GENDER ...... 27 3.3. AGE PYRAMID OF THE POPULATION ...... 29 3.4. PREGNANT WOMEN BY AGE ...... 30 3.5. HOUSING CHARACTERISTICS ...... 31 3.6. HOUSEHOLD POSSESSIONS ...... 32 4. KNOWLEDGE, ATTITUDES AND PRACTICES ON MALARIA ...... 33 4.1. HEARD ABOUT MALARIA AND SOURCE OF INFORMATION ...... 33 4.2. KNOWLEDGE ABOUT CAUSE, SYMPTOMS AND LETHALITY OF MALARIA ... 35 4.3. ATTITUDE AND PRACTICES FOR MALARIA PREVENTION ...... 37 4.3.1. Treatment Seeking Behaviour ...... 37
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4.3.2. Self Treatment of malaria ...... 38 5. COVERAGE OF MALARIA PRVENTION INTERVENTIONS ...... 45 5.1. INDOOR RESIDUAL SPRAYING ...... 45 5.2. LONG LASTING INSECTICIDE TREATED NETS (LLINS) ...... 46 5.2.1. Ownership, acquisition & source of long lasting insecticide treated nets .. 46 5.2.2. Coverage of LLINs in GF Covered and non Covered Union Councils...... 48 5.2.3. Usage of Mosquito Nets ...... 52 6. PARASITE PREVALENCE ...... 55 6.1. ELIGIBLE PERSONS TESTED FOR MALARIA ...... 55 6.2. PREVALENCE OF MALARIA PARASITES ...... 56 6.3. SLIDE POSITIVITY RATE ...... 58 6.4. PREVALENCE OF FEVER AT THE TIME OF SURVEY ...... 59 6.5. FEVER CASES POSITIVE ON RDTs...... 60 6.6. FEVER CASES POSITIVE ON MICROSCOPY ...... 60 6.7. MORTALITY DUE TO MALARIA (VERBAL AUTOPSY) ...... 60 7. HOT SPOTS/HIGH RISK UCS ...... 63 8. HEALTH FACILITY SURVEY ...... 75 8.1. STAFF WORKING FOR MALARIA IN HEALTH FACILITIES (2012 & 2013) ...... 75 8.2. EQUIPMENT & SUPPLIES AT HEALTH FACILITIES OF 38 DISTRICTS ...... (2012 -13) ...... 77 8.3. IN-STOCK POSITION OF ANTI-MALARIAL DRUGS AND LLINS ...... 79 8.4. STOCK-OUT POSITION OF ANTI-MALARIALS, RDTS AND LLINS IN PEAK SEASONS OF MALARIA (AUGUST to OCTOBER 2013) ...... 82 8.5. MALARIA CASE MANAGEMENT PRACTICES ...... 83 8.5.1. Treatment of clinical malaria ...... 84 8.5.2. Treatment and referral of uncomplicated and complicated malaria cases as per guidelines ...... 86 8.5.3. Time elapse between smear taken and result received ...... 89 8.5.4. Health facilities designated as LLINs distribution points ...... 89 8.6. SKILL DEVELOPMENT ...... 89 8.7. MALARIA SITUATION IN HEALTH FACILITIES IN 38 DISTRICTS (2012-13) .... 92 8.8. SEASONAL VARIATION OF MALARIA BY PROVINCE (2012-13) ...... 95 9. IMPLICATIONS OF MIS RESULTS ...... 97 10. APPENDIX-A: DISTRICT WISE DATA ...... 99 10.1. HOUSEHOLD POPULATION AND CHARACTERISTICS ...... 99 10.2. HOUSEHOLD POPULATION BY SIZE, AGE AND GENDER ...... 101 10.3. PREGNANT WOMEN BY AGE ...... 105 10.4. KNOWLEDGE, ATTITUDES AND PRACTICES ON MALARIA ...... 106 10.5. KNOWLEDGE ABOUT CAUSE, SYMPTOMS & LETHALITY OF MALARIA ...... 107 10.6. ATTITUDE AND PRACTICES FOR MALARIA PREVENTION ...... 109 10.7. COVERAGE OF MALARIA PRVENTION INTERVENTIONS ...... 117 10.7.1. Indoor Residual Spraying Coverage ...... 117 10.8. LONG LASTING INSECTICIDE TREATED NETS CHARACTERISTICS & USAGE 118 10.8.1. Ownership, acquisition & source of LLINs ...... 118
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10.8.2. Source of LLINs received ...... 119 10.9. NET POSSESSION OTHER THEN LLIN ...... 120 10.10. USAGE OF MOSQUITO NETS ...... 122 10.10.1. Usage of LLINs by pregnant women ...... 124 10.10.2. Net coverage in Global Fund supported UCs ...... 125 10.11. PARASITE PREVALENCE ...... 126 10.11.1. Prevalence of malaria parasites ...... 126 10.12. PREVALENCE OF FEVER AT THE TIME OF SURVEY ...... 131 10.12.1. Fever cases positive on RDTs ...... 133 10.13. HOT SPOTS/HIGH RISK DISTRICTS ...... 135 10.14. STAFF WORKING FOR MALARIA AT THE HEALTH FACILITIES ...... 138 10.15. EQUIPMENT AND SUPPLIES POSITION ...... 140 10.16. ANTI-MALARIA DRUGS AND LLINS OUT OF STOCK (Aug-Oct) ...... 141 10.17. MALARIA CASE MANAGEMENT PRACTICES ...... 145 10.18. MALARIA SITUATION...... 152 11. APPENDIX-B: SURVEY TEAMS ...... 161 12. APPENDIX-C: PHOTOGRAPHS OF THE SURVEY ACTIVITIES...... 169 13. APPENDIX-D: QUESTIONNAIRES ...... 181
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LIST OF TABLES
Table 1: Demographic Indicators of Pakistan ...... 3 Table 2: Key Health Indicators of Pakistan ...... 5 Table 3: Malaria Statistics Pakistan - 2012 ...... 8 Table 4: List of 38 Highly Malaria Endemic Districts in Pakistan ...... 20 Table 5: Field team composition in each district ...... 21 Table 6: Number of households, number of interviews and response rates ...... 25 Table 7: Head of household by gender in 38 districts ...... 26 Table 8: Age of the respondents by Province ...... 27 Table 9: Households size and gender distribution by Province ...... 28 Table 10: Population by age and gender in 38 districts ...... 28 Table 11: Age and number of pregnant women in 38 districts ...... 30 Table 12: Housing Characteristics in 38 districts ...... 31 Table 13: Household Possessions (n=8724) ...... 32 Table 14: Percentage of people (≥15) who heard about malaria in 38 districts ...... 33 Table 15: Source of information about Malaria (15 years & above age) ...... 34 Table 16: Information about LLINs and its source ...... 35 Table 17: Percentage of people (age 15 years and above) who knew the cause, symptoms and prevention of malaria (38 GF Districts) ...... 36 Table 18: Treatment seeking behavior in fever cases at the time of survey ...... 37 Table 19 : Treatment-seeking behavior in those who ever had fever (38 districts) ...... 38 Table 20: Self treatment of malaria ...... 39 Table 21: Preference for using public or private facility and the type of health care provider for treatment of fever ...... 40 Table 22: Reasons for not using government health facilities...... 41 Table 23: Distance of government health facilities from the place of residence of the surveyed households ...... 42 Table 24: Health facility access: round trip cost (Rupees) incurred by the households . 43 Table 25: Time taken to access the health care provider ...... 44 Table 26: Households sprayed using IRS in the last 12 months in 38 districts ...... 46 Table 27: Households having at least one LLIN or any other mosquito net (traditional untreated nets) (38 districts) ...... 47 Table 28: Time and source of acquisition of nets ...... 48 Table 29: Distribution of LLINs in Union Councils covered or not covered with Global 49 Table 30: Percentage of all persons who slept under LLINs the night preceding the survey ...... 52 Table 31: Province wise percentage of children under five years who slept under LLIN the night preceding the survey...... 53 Table 32: Province wise percentage of pregnant women who slept under LLIN the night preceding the survey ...... 54 Table 33: Persons tested for malaria using microscopy in 19 Districts of Round 10 ..... 55 Table 34: Province wise prevalence of malaria (Microscopy+ RDTs) and PV: PF ratio .. 56 Table 35: Prevalence of malaria by gender, age & marital status (microscopy+RDTs) . 57
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Table 36: Slide positivity rate of malaria in 19 districts of Round-10 ...... 58 Table 37: Prevalence of fever at the time of survey in Round-10 ...... 59 Table 38: Age wise prevalence of fever at the time of survey in Global Fund Round-10 districts ...... 59 Table 39: Results of RDT in fever cases in 19 districts of Round-10 ...... 60 Table 40: Proportion of fever and non fever cases positive on microscopy ...... 60 Table 41: Mortality in the last 10 years by gender and age ...... 61 Table 42: Relationship of the deceased with Head of Household ...... 62 Table 43: Slide Positivity Rate by Union Councils ...... 63 Table 44: Categories of health facilities surveyed in GF 7 and 10 districts ...... 75 Table 45: Equipment and supplies at Microscopy Centres in Year 2012 ...... 78 Table 46: Equipment and supplies for Microscopy Centres in Year 2013 ...... 79 Table 47: Stock position of anti malaria drugs and LLINs (2012) ...... 80 Table 48: Stock position of anti Malaria drugs and LLINs in health facilities on the day of visit in 38 districts (2013) ...... 81 Table 49: Stock out of anti malarial and RDTs provided through GF R-10 grant during three months (August, September, October) 2013 in 38 districts ...... 82 Table 50: Number of health facilities performing malaria microscopy at RHCs, THQs and DHQs in 38 Districts ...... 83 Table 51: Number of health facilities performing RDTs at BHUs in 38 Districts ...... 84 Table 52: Treatment of clinical malaria ...... 85 Table 53 : Uncomplicated Malaria cases treated as per guidelines ...... 86 Table 54: Treatment given at the time of referral of complicated malaria cases by province...... 87 Table 55: Type of health facilities where complicated malaria cases are referred ...... 88 Table 56: Staff trained on National malaria guidelines in surveyed facilities of 38 districts (2013) ...... 90 Table 57: Staff trained on national malaria guidelines in 38 districts (2012) ...... 91 Table 58 Respondents (household) by gender in 38 districts ...... 99 Table 59: Respondents by age in 38 districts ...... 100 Table 60: Households with population and size in 38 districts ...... 101 Table 61: District wise population by Age ...... 102 Table 62: District wise population by Gender ...... 103 Table 63: Population by age and Gender in 38 GF supported districts (pyramid) ...... 104 Table 64: Province and district wise surveyed population by Age (years) ...... 104 Table 65: Pregnant women with Reproductive age in Round-7 and Roud-10 districts 105 Table 66: Heard about Malaria and source of information (age 15 years & above).... 106 Table 67: Percentage of people (15 years and above) who knew the cause, symptoms, lethality and prevention of malaria (38 GF Districts). (The proportion is out of 25943 individuals who heard about malaria)...... 107 Table 68: Importance of Malaria by district ...... 108 Table 69: Treatment seeking behavior in cases suffering from fever at the time of survey by district ...... 109 Table 70: Treatment-Seeking behavior in those who ever had fever (38 districts) ..... 110
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Table 71: Self treatment of Malaria in 38 districts ...... 111 Table 72: Preference for using public or private facility and the type of health care provider for fever ...... 112 Table 73: Reasons for not using Government Health Facilities ...... 113 Table 74: Distance of Government Health Facilities from the place of residence of the surveyed households by district ...... 114 Table 75: Health facility access: Round trip cost (Rs.) incurred by the households ..... 115 Table 76: Time taken to access the health care provider ...... 116 Table 77: Households sprayed using IRS in the last 12 months in 38 districts ...... 117 Table 78: Households having at least one LLIN or any other mosquito net (38 distt.) 118 Table 79: Households with at least one LLIN in 38 districts and period when nets were received ...... 119 Table 80: Proportion of net possession by households other than LLINs in 38 Distt .. 120 Table 81: Households with at least one LLIN in 38 Distt. and source of nets received 121 Table 82: Percentage of all persons who slept under LLINs the night preceding ...... 122 Table 83: Percentage of children under 5 years of age who slept under LLIN last night ...... 123 Table 84: Percentage of pregnant women who slept under LLIN last night in 38 districts ...... 124 Table 85: Distribution of LLINs in Union Councils covered or not covered with Global fund support in 19 districts of Round-7 ...... 125 Table 86: Persons tested for Malaria using microscopy by Districts ...... 126 Table 87: Prevalence of malaria (microscopy+ RDTs) and PV: PF ratio by districts ..... 127 Table 88: Prevalence of Malaria (microscopy and / or RDTs) in 19 districts of Round 10 by gender ...... 128 Table 89: Prevalence of Malaria (microscopy and / or RDTs) in 19 districts of Round 10 ...... 129 Table 90: Province and district wise estimated number of cases of malaria according to malaria prevalence ...... 130 Table 91: Prevalence of fever at the time of survey by gender in Roud-10 districts ... 131 Table 92: Prevalence of fever at the time of survey by age in Round 10 districts ...... 132 Table 93: Prevalence of Malaria (Microscopy and/or RDTs) in 19 Distt. of Round 10 . 132 Table 94: Results of RDT in fever cases in 19 districts of Round-10 ...... 133 Table 95: Results of RDTs by gender in Round-10 districts ...... 134 Table 96: Microscopy results by Union Council in 19 districts of Round-10 ...... 135 Table 97: Staff working for malaria at Health facility by province and district (2012) 138 Table 98: Staff working for malaria at Health facility by province and district (2013) 139 Table 99: Number and percentage of BHUs with all inputs for RDT Centre in place by districts (2013) ...... 140 Table 100: Overall Stock out of Anti Malarial and RDTs during three months (August, September, October) 2013 ...... 141 Table 101: Stock out of Anti Malarial and RDTs in August 2013 in 38 districts ...... 142 Table 102: Stock out of Anti Malarial and RDTs in September 2013 in 38 districts ...... 143 Table 103: Stock out of Anti Malarial, and RDTs in October 2013 in 38 districts ...... 144
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Table 104: Malaria Diagnosis Practices (microscopy) at RHCs, THQs and DHQs in the surveyed facility in 38 districts...... 145 Table 105: Malaria Diagnosis Practices (RDTs) in the surveyed facility (BHUs) in 38 districts (2013) ...... 146 Table 106: Time elapse between the smear taken and result received at microscopy centres (n=80) by districts ...... 147 Table 107: Time elapse between the result received and treatment started...... 148 Table 108: Referral of complicated malaria cases by surveyed health facilities in ...... 149 Table 109: Facilities having National malaria guidelines (2012) ...... 150 Table 110: Facilities having National malaria guidelines (2013) ...... 151 Table 111: Malaria situation in 2012 – Microscopy (Sindh) ...... 152 Table 112: Malaria situation in 2013 – Microscopy (Sindh) ...... 152 Table 113: Malaria situation in 2012 – Microscopy (Balochistan) ...... 153 Table 114: Malaria situation in 2013 – Microscopy (Balochistan) ...... 153 Table 115: Malaria situation in 2012 – Microscopy (KPK) ...... 154 Table 116: Malaria situation in 2013 – Microscopy (KPK) ...... 154 Table 117: Malaria situation in 2012 – Microscopy (FATA) ...... 155 Table 118: Malaria situation in 2013 – Microscopy (FATA) ...... 155 Table 119: Malaria situation (RDTs ) in 2012 (Sindh) ...... 156 Table 120: Malaria situation (RDTs ) in 2013 (Sindh) ...... 156 Table 121: Malaria situation (RDTs) in 2012 (Balochistan) ...... 157 Table 122: Malaria situation (RDTs ) in 2013 (Balochistan) ...... 157 Table 123: Malaria situation (RDTs ) in 2012 (KPK) ...... 158 Table 124: Malaria situation (RDTs ) in 2013 (KPK) ...... 158 Table 125: Malaria situation (RDTs ) in 2012 (FATA) ...... 159 Table 126: Malaria situation (RDTs ) in 2013 (FATA) ...... 159
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LIST OF FIGURES
Figure 1: Overall PV-PF Ratio (2008-12) in Pakistan ...... 9 Figure 2: Malaria parasite trends (2007-12) ...... 9 Figure 3: Trends in malaria indicators Pakistan (2007-12) ...... 10 Figure 4: Annual Parasite Incidence per 1000 Population (2009-12) ...... 11 Figure 5: Province wise distribution of LLINs in union councils covered and not covered with Global Fund support in Round-7 ...... 50 Figure 6: District wise coverage of LLINs in 19 districts of R-7 ...... 51 Figure 7: District wise coverage of LLINs in 19 districts of R-10 ...... 51 Figure 8: Union councils: Gul Imam, Dabarah, Tank Urban, Ranwal, ...... 64 Figure 9: Union councils: Agra, Behlola, Dakki, Daulatpura, Haji Zai, Hisara Nehri, Maira Prang and Shabqadar...... 65 Figure 10: Union councils: Aman Kot, Dag Behsud, Jehangira, Kaka Sahib, ...... 65 Figure 11: Union councils: Gara Isa Khan, Giloti, Kath Garh, Lar, Mohra and Zindani ...... 66 Figure 12: Union councils: Bukera Shrif, Chamber, Desori, Missan and Sheikh Moosa ...... 66 Figure 13: Union councils: Kangoro, Khan, Khudad, Makhan Samoo, ...... 67 Figure 14: Union councils: Bonistan, Chitkan, Gram Kan, Kallag, Sordo and Tasp ...... 67 Figure 15: Union Councils: Jamak, Janobicit, Moorvali, Raaskoh, Sarawan & TohMalak ...... 68 Figure 16: Union councils: Amin Abad, Amri, Nokhundi, Padag and Z. Balanosh ...... 68 Figure 17: Union councils: Ali Zai, B.Barshor, Barshor, Khano Zai Kariz, ...... 69 Figure 18: Union councils: Durak, Guryasa, Kangri, Musa Khawa and Saddar Bazar ...... 69 Figure 19: Mohamand Agency with Tehsils ...... 70 Figure 20: Orakzai Agency with Tehsils ...... 70 Figure 21: North Waziristan Agency with Tehsils ...... 71 Figure 22: South Waziristan Agency with Tehsils ...... 71 Figure 23: FR Peshawar Agency ...... 72 Figure 24: FR D.I. Khan Agency ...... 72 Figure 25: FR Bannu, FR Lakki Marwat and FR Tank Agencies ...... 73 Figure 26: Staff working for malaria at Health facility by Province (year 2013) ...... 76 Figure 27: Staff working for malaria at Health facility by Province (year 2012) ...... 77 Figure 28: Facilities having national malaria guidelines in 2012 and 2013 ...... 88 Figure 29: Surveyed health facilities designated as distribution point for LLINs (2013) ...... 89 Figure 30: Staff trained on national malaria guidelines in surveyed facilities ...... 92 Figure 31: Suspected malaria cases and slide examination and microscopy in 2012- 2013 ...... 93 Figure 32: Slide positivity rate and PV to PF ratio in 2012 & 2013 ...... 93 Figure 33: Suspect identification and RDTs done at the RDT Centres in 2012 & 2013 (Jan-Oct) ...... 94 Figure 34: Positive malaria cases on RDTs (2012 & 2013) ...... 94 Figure 35: Trend in the proportion of malaria cases reported by the health facilities ...... 95
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ACRONYMS AND ABBREVIATIONS API Annual Parasite Incidence ACT Artemisinin-combination therapy CDC Centers for Disease Control and Prevention FATA Federally Administered Tribal Areas KPK Khyber Pakhtunkhwa NCD Non-communicable diseases PDHS Pakistan Demographic & Household survey UNHCR United Nation High Commissioner for Refugees WHO World Health Organization MDGs Millennium Development Goals BHU Basic Health Unit RHC Rural Health Centre THQ Tehsil Head Quarter Hospital MNCH Maternal Newborn and Child Health NHSRC National Health Services, Regulation and Coordination DOMC Directorate of Malaria Control MCP Malaria Control Programme GF Global Fund PV Plasmodium vivax PF Plasmodium falciparum RDTs Rapid diagnostic tests MC Microscopy LLINs Long lasting insecticide treaded nets SPR Slide positivity rate IRS Indoor residual spraying GFATM Global Fund to Fight against AIDs, TB and Malaria MIS Malaria Indicator Survey FR Frontier regions UCs Union Councils PPS Probability Proportionate Size PI Principal Investigator Co-I Co-Investigator MO Medical Officer EDOH Executive District Officer (Health) GIS Geographical Information System KAP Knowledge Attitude and Practices LHW Lady Health Worker Km Kilometers Govt. Government NGO Non Governmental Organization DHIS District Health Information System
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FOREWORD
Malaria continues to be a major public health problem in Pakistan, with an estimated 1.6 million cases occurring annually. Children under age 5 and pregnant women are most vulnerable to malaria. The aim of the malaria control program is to reduce the burden of disease by scaling-up appropriate interventions including prompt and effective antimalarial drug treatment, use of insecticide-treated nets and indoor residual spraying by scaling up access to malaria prevention and treatment to all persons living in malaria risk areas. The ultimate goal is to achieve universal coverage in the prevention and treatment of malaria towards attainment of the national vision of “Malaria Free Pakistan”. The interventions, key strategic approaches and performance targets are in line with the global Roll Back Malaria targets for malaria control and elimination.
Malaria indicator survey-2013 (MIS) provides an opportunity to measure the coverage of interventions targeted at the household level, such as insecticide treated nets, indoor insecticide spraying, and behavior change communication. The MIS helps in evaluating progress against malaria control targets.
This report presents the findings of the Pakistan Malaria Indicator Survey-2013 in the general population that was conducted between August-November 2013. The survey targeted the Global Fund supported 38 high malaria burdened districts of Sindh, Balochistan, Khyber Pakhtunkhwa provinces and FATA region. The main purpose of the survey was to estimate malaria prevalence and measure coverage of malaria interventions, including long lasting insecticide-treated nets (LLINs), indoor residual spraying (IRS), and access to parasitological diagnosis and antimalarial treatment for febrile illness in general population. In addition health facility survey was also conducted to evaluate the number of malaria cases being diagnosed at these sites, their treatment and referral and the availability of medicines. Demographic data was collected to provide understanding of the factors that may potentially increase the risk of malaria transmission in these 38 districts. These included population and household composition, knowledge, attitudes and practices used for malaria prevention.
The findings of this survey will help the Directorate of Malaria Control in understanding the true malaria situation and gaps that need to be addressed in 38 high malaria burdened districts of Pakistan. This would eventually guide the National Malaria Control Program on strategizing their inputs for achieving the target of malaria control and elimination in Pakistan.
I must commend the untiring efforts of Core Survey Team, Dr Huma Qureshi, Team Leader and Principal Investigator, Dr Muhammad Arif Munir, Co Team Leader and Co-Principal Investigator, Dr Nauman Safdar Public Health Specialist and Co-investigator, Khawaja Asim, Financial Manager and Mr. Mehmood Ahmed, Survey Coordinator.
Director General Government of Pakistan Ministry of National Health Services Regulation and Coordination
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ACKNOWLEDGEMENTS
Pakistan Medical Research Council would like to extend special thanks to Mr. Imtiaz Elahi, Secretary Ministry of National Health Services Regulation and Coordination and Dr Jahanzeb Orakzai, Director General, Ministry of NHSR&C for their valuable and constant support throughout the survey. We wish to express our special thanks to Mr. Muhammad Aslam Khan, Director, Directorate of Malaria Control for his kind facilitation during inception and implementation of this survey. We greatly acknowledge the contributions of Mr. Muhammad Mukhtar, Senior Scientific Officer, Dr Suleman Memon, Epidemiologist, Dr Abdul Majeed Jaffar, Senior Project Officer, Dr Saba Farooqi, Manager M&E, Mr. Naveed Chaudhry, Manager PSM, Mr. Kashif Rasheed, Manager Finance, Dr Inamullah Kakar, Programm Officer and Miss Tayyaba Gul, Project Officer of the Directorate of Malaria Control. We gratefully acknowledge and thank Mr. Khalid Mehmood, Consultant, Sample Survey Design (Former Deputy Director General FBS) for sample size calculation. We sincerely appreciate the technical and supportive role of Dr. Muhammad Imran, Project Director, Dr Mah Talat, Training Coordinator & Manager BCC, Mr. Alamgir Khan, Manager Logistics and Mr. Ali Asghar, Manager M&E Save the Children. We wish to extend our deep gratitude to Dr Qutbuddin Kakar, Programme Officer, WHO Pakistan Country Office, Islamabad for his technical inputs. Special thanks are due to the Dr Nahid Jamali, Director, Directorate of Malaria Control, Sindh, Dr. Ayub Kakar, Provincial Coordinator and Dr Sultan Mehmood Paracha, Epidemiologist, Malaria Control Programme, Baluchistan, Dr Muhammad Asif, Provincial Coordinator (RBM), Malaria Control Programme, Khyber Pakhtunkhwa Khwa, Dr Qasim Abbas, Programme Manger, IVPM, Directorate of Health Services, FATA and Mr. Naeem Durrani, Merlin Pakistan for their cooperation and support during the survey. The monitoring and supervision by the Provincial and District Data Management Units & M&E officers is highly acknowledged. Data processing was supervised by Mr. Rizwanullah, Statistical Officer, PMRC and data analysis was done by Syed Ejaz Alam, Statistical Officer, PMRC Research Centre, JPMC, Karachi. We commend their untiring efforts and dedication for the timely completion of task. Our special thanks to Mr. Ibrar Rafique, Mrs. Sumaira Abid, Dr Faiza Bashir and Dr Najma Javed for Urdu translation of questionnaire and field manual. We are thankful to Mr. Muhammad Arif Nadeem Saqib for editorial assistance and Mr. Khalid Mehmood and Mr. Zulfiqar for typing the Urdu questionnaire and to all PMRC Officers and staff who contributed in achieving this very important task. We wish to thank Mrs. Farzana Naheed for mapping malaria hot spots. In addition the untiring efforts of Provincial Coordinators, Balochistan, Mr. Munir Ahmed Khan Lodhi (Round-10 districts) and Mr. Sardar Muhammad Khan Durrani (Round-7 Districts), Dr Muhammad Hassan, Provincial Coordinator, KPK/FATA and Dr. Muhammad Ayaz Mustufa, Provincial Coordinator Sindh, are highly acknowledged. We appreciate the efforts of the monitoring teams who despite the difficult field conditions, visited the field areas and monitored the survey activities. Last but not the least we would like to express our sincere thanks and gratitude to the District Coordinators, survey teams, data entry teams and above all the household members/community who participated in the survey.
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EXECUTIVE SUMMARY
Malaria is a major public health problem in Pakistan. With an estimated burden of 1.6 million cases annually, Pakistan is categorized by WHO in Group-3 countries of the Eastern Mediterranean Region along with Sudan, Afghanistan, and Yemen. These four countries account for 98% of the confirmed malaria cases in the region. Mass population movements within the country and across international borders, natural disasters and civil unrest, unpredictable transmission patterns due to climatic changes, poor socioeconomic conditions, declining health infrastructure, resource constraints, poor access to preventive and curative services has contributed in making malaria a public health problem.
Malaria is typically unstable in Pakistan and almost all age groups are at risk of acquiring infection. However, children below 5 years of age and pregnant women are at higher risk of infection. In Pakistan, malaria transmission is seasonal, with peaks around September for vivax malaria and around October for falciparum malaria. Plasmodium vivax (Pv) forms a latent stage in liver, therefore another peak is seen in early summer (April) due to relapse resulting from transmission in the previous year. The annual parasite incidence varies widely between provinces ranging from as low as 0.10 cases per 1000 population in AJK to 7.82 in Balochistan and 6.82 in FATA. Proportion of Plasmodium falciparum (Pf) also varies widely between 2.5% - 44.3%. Maximum proportion of falciparum cases (i.e. 44.3%) is reported from Balochistan province followed by 27% cases in the Sindh province. In 2012 the overall Pv to Pf ratio was 76:24 in Pakistan
Malaria control in Pakistan focuses on four major intervention areas which include (1) effective case management through early diagnosis and prompt and appropriate treatment, (2) integrated vector management, particularly in combining the use of indoor residual spraying (IRS) and long-lasting insecticide-treated nets (LLINs), (3) a strong epidemiological surveillance system, and (4) a comprehensive information, education and communication (IEC) campaign.
Pakistan was successful in receiving the Global Fund Round 10 Malaria grant targeting 38 highly endemic districts. These 38 target districts include 19 districts of the Global Fund Round 7 and additional 19 districts for Round 10. The total target population living in these districts was estimated to be 24.84 million.
The Malaria Indicator Survey (MIS) was planned to measure the progress of these interventions and thus help in formulating the country’s future malaria elimination strategies. The current MIS survey 2013 which represented household and health facility survey was aimed at assessing coverage of key malaria control interventions and determining malaria prevalence in 19 districts of GF-10 population. The project for this survey was developed and conducted by the Pakistan Medical Research Council along
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The sampling methodology for the Malaria Indicator Survey was a two-stage stratified cluster sample of 11,100 households selected from 222 union councils of 38 high risk districts. All union councils of 38 districts were randomized to select 222 UCs. Field-work was conducted during September to November 2013 by 38 survey teams using standardized household and health facility questionnaires. Trained field staff administered the questionnaire while, health facility survey was exclusively conducted by the district coordinators who were medical doctors and had long experience in district health management services. To measure malaria prevalence, malaria microscopy and rapid diagnostic tests (RDTs) were performed. For microscopy thick and thin smear slides were taken from all individuals in the household who consented to be tested but RDTs were performed only on individuals who had fever during last 72 hours or at the time of survey.
The following sections summarize the main findings of the Malaria Indicator Survey 2013:
Household Survey
A total of 11100 households were surveyed comprising of 67971 persons with a mean size of 6.2 persons per house. Of the total population 53.6% were males and 46.4% were females. About 42% of the population was under 15 years of age with 13% less than five years and 49% were between 15-49 years. Seventy-one percent of the households were headed by men.
Almost two-third of the houses was kacha houses. Electricity was available in 86% houses. About 33.8% households had only one sleeping room and over 80% houses had windows covered with some kind of screen. Mobile phone owners were 86% and 51% owned a television, indicating access to information technologies.
Over 81% population had received malaria related health education messages mostly through family members (52.5%), health facility (52%) and electronic media (25.9%). Information about LLINs was also passed on to them from health facility (37%), television (16%) and Lady Health Workers (LHWs) (13%). Mosquito as the causative agent and fever as its main presenting sign was known by majority and 79% knew that malaria can kill if not treated.
Early treatment for fever (within 24 hours) through a heath care provider was reported by majority (65%), though 28% also self treated malaria mainly using allopathic medicines.
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Only 50% population was seeking treatment from government health facility as rest were either dissatisfied with the services (44.3%) or the medicines were not available (42.3%). Though 90% health facilities were within 5 Km distance yet 50% population was spending between Rs 200-500 to reach the facility. Once reached, 77% were seen by a health care provider within an hour.
Only 11% houses had been sprayed in the past 12 months, of these 62.6% were sprayed by the government malaria control program.
One third of the population in high risk districts had at least one LLIN which in 50% cases was provided by the government and in 37% by NGOs. About 21% population was using nets other than LLINs. Though 35% family members reported having slept under LLIN in the previous night but the practices remained low among the high risk groups as only 21% children under 5 years and 28% pregnant women slept under a mosquito net.
Overall malaria prevalence per 1000 population was 15.9 cases. The prevalence was highest in FATA (27.5) followed by KPK (12.5), Balochistan (11.3) and Sindh (1.8). Overall the PV: PF ratio was 84:16. Highest falciparum prevalence was found in FATA (4.5/1000 population) followed by Balochistan (4.0/1000 population). Overall there was no difference in the prevalence among males (16.3/1000 population) and females (15.6/1000 population). Maximum prevalence was in children between 5-14 years (18.1/1000 population) followed by under five years of age (16.1/1000 population). The prevalence was almost similar (14/1000) in those aged >15 years. Overall slide positivity rate was 1.41% (5.6% in fever cases and 1.3% in non fever cases). An unusually higher slide positivity rate was seen in North Waziristan (7.8%) whereas in other districts it ranged between 0-3.2 percent.
A total of 717 (2.3%) cases had fever at the time of survey with no gender predominance. Among those with fever, 3.6% were children below 5 years of age, 2.5% were the children between 5-14 years and 1.9% were 15 years and above. Rapid diagnostic tests were performed in all fever cases and 72 (10%) were positive. Out of these 46 (63%) were Plasmodium vivax, 17 (24%) were Plasmodium falciparum positive and 9 (13%) were mixed infections. Out of 717 fever cases, 5.6% were positive on microscopy. About 1.3% cases without fever were also positive for malaria parasites on microscopy.
Out of 111 Union Councils surveyed, 13 (12%) showed a slide positivity rate of less than 1%, 26 (23%) had between 1-5% and 10 (9%) had more than 5% (hot spot). In the remaining 62 (56%) Union Councils slide positivity rate was zero.
The head of the household was asked to recall if any death had occurred in the family during last 10 years due to malaria (verbal autopsy). Over all 42 deaths were recalled; of these 18 were children below 5 years of age, 9 were between 5-14 years and 15 were ≥15 years of age.
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Health Facility Survey
The health facility survey collected data on services provided, staff working for malaria and trainings received in 38 districts. A total of 198 health facilities (106 BHUs, 35 RHCs, 17 THQs, 31 DHQs and 9 others) were surveyed. These included 66% GF supported and 34% not supported facilities.
Overall 80.2% BHUs, 62.9% RHCs, 82.4% THQs and 64.5% DHQs had a medical officer involved in malaria case management. Similarly the malaria staff (microscopists, laboratory technicians, CDC supervisors) in these health facilities was 83.5% at BHUs, 82.9% in RHCs, 94.1% in THQs and 96.8% in DHQs. A substantial improvement in the number of medical officers and staff was seen between 2012 and 2013.
About 93% facilities were performing microscopy and 56% were performing RDTs while rest was referring suspected malaria cases to other health facilities.
On spot availability of antimalarial drugs on the day of visit showed that 97% facilities had recommended antimalarials and 78% LLINs in stock.
Stock out of antimalarial drugs, RDTs and LLINs situation was analyzed during the 3 peak malaria months (August, September and October). Almost all facilities showed low stock out of antimalarial drugs and RDTs at the facilities strengthened through Global Fund support.
Most of the health facilities were treating uncomplicated malaria cases as per national guidelines while, complicated malaria cases were referred to either DHQ or tertiary care after giving standard antimalarials. Majority of health facilities (94%) were treating clinical malaria with chloroquine.
Out of 198 health facilities, 61% had medical officers trained on case management guidelines, 56% on microscopy, 62% on RDTs, 74% on Malaria Information System (MIS) and 47% on LLIN distribution strategy. When compared with 2012 there was a marked improvement in the staff trained during 2013.
Data was collected from selected health facilities performing microscopy and RDTs to compare the trend over two years. In 2013 there were 17,441 additional suspected malaria cases with 15082 additional slides prepared and 13,717 additional RDTs done. A decrease in the overall slide positivity rate was noted in 2013 (13.3%) as compared to 2012 (16.8%).
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1. INTRODUCTION
1.1. GEOGRAPHY, CLIMATE AND DEMOGRAPHY
1.1.1. Geography The geography of Pakistan is a remarkable combination of landscapes varying from plains to deserts, forests, hills, and plateaus. The variety of landscape divides Pakistan into six major regions: the North High Mountainous Region, the Western Low Mountainous Region, the Balochistan Plateau, the Potohar Upland, the Punjab and the Sindh Plains. Pakistan is located between 240 and 370 N latitude and between 610 and 750 E longitudes. On its east and south east lies India, to the north and northwest is Afghanistan, to the west is Iran, on the northeast is China and in the south is the Arabian Sea. Pakistan is the 36th largest nation in the world by total area. It covers land area of 796,095 square kilometers. It has a 1,046 km coastline along the Arabian Sea and the Gulf of Oman in the south and shares 2430 and 909 Kms of border with Afghanistan and Iran respectively. The Indus River and its numerous tributaries (one of the world's most significant waterways) drain the entire country. In addition five major rivers traverse the country from north east to south west. They are the perennial rivers whose water is utilized for the irrigation purposes through a vast network of canals. There is a big problem of salinity and water logging in the country, which has increased the malariogenic potential to a considerable level. The administrative units of Pakistan consist of five provinces (Punjab, Sindh, Khyber Pakhtunkhwa, Balochistan and Gilgit Baltistan), one federal capital territory, a group of federally administered tribal areas (FATA) and an autonomous states Azad Jammu and Kashmir. Every province is divided into districts which are divided into tehsils (sub- districts). The tehsils are further subdivided into union councils (UCs) which are the lowest administrative unit.
1.1.2. Climate The climate of Pakistan is as diverse as its topography. Pakistan lies in the temperate zone, immediately above the north tropic of cancer. The climate varies from tropical to temperate. Arid conditions exist in the coastal south, characterized by a monsoon season with adequate rainfall and a dry season with lesser rainfall, while abundant rainfall is experienced by the province of Punjab, and wide variations between extremes of temperature at given locations. There are four distinct seasons; a cool, dry winter from December through February; a hot, dry spring from March through May; the summer rainy season or southwest monsoon period, from June through September; and the retreating monsoon period of October and November. Rainfall can vary radically
1 from year to year, and successive patterns of flooding and drought are common. Rainfall varies from as little as less than 10 inches a year to over 150 inches a year, in various parts of the nation.
Climate of Sindh Province: Sindh lies in a tropical to subtropical region. It is hot in the summer and mild to warm in winter. Temperatures frequently rise above 46 °C (115 °F) between May and August, and the minimum average temperature of 2 °C (36 °F) occurs during December and January in the northern and higher elevated regions. The annual rainfall averages about seven inches, falling mainly during July and August. The southwest monsoon wind begins to blow in mid-February and continues until the end of September, whereas the cool northerly wind blows during the winter months from October to January. Sindh lies between the two monsoons—the southwest monsoon from the Indian Ocean and the northeast or retreating monsoon deflected towards it by the Himalayan mountains—and escapes the influence of both. The region's scarcity of rainfall is compensated by the inundation of the Indus twice a year, caused by the spring and summer melting of Himalayan snow and by rainfall in the monsoon season.
Climate of Balochistan Province: The climate of the upper highlands is characterized by very cold winters and hot summers. In the lower highlands, winters vary from extremely cold in northern districts Ziarat, Quetta, Kalat, Muslim Baagh and Khanozai to milder conditions closer to the Makran coast. Winters are mild on the plains, where temperature never fall below freezing point. Summers are hot and dry, especially in the arid zones of Chagi and Kharan districts. The plains are also very hot in summer, with temperatures reaching 50 °C (122 °F).The highest temperature, 53 °C (127 °F), was recorded in Sibi on 26 May 2010,[16] exceeding the previous record, 52 °C (126 °F). Other hot areas include Turbat, and Dalbandin. The desert climate is characterized by hot and very arid conditions. Occasionally strong windstorms make these areas very inhospitable.
Climate of Khyber Pakhtunkhwa: The climate of Khyber Pakhtunkhwa varies immensely for a region of its size, encompassing most of the many climate types found in Pakistan. The air is generally very dry; consequently, the daily and annual range of temperature is quite large. Rainfall also varies widely. Although large parts of Khyber Pakhtunkhwa are typically dry, the province also contains the wettest parts of Pakistan in its eastern fringe. On the southern flanks of Nanga Parbat and in Upper and Lower Dir Districts, rainfall is much heavier than further north. The southern slopes of Khyber Pakhtunkhwa are the wettest part of Pakistan. Annual rainfall ranges from around 500 millimeters (20 inches) in the most sheltered areas to as much as 1,750 millimeters (69 inches) in parts of Abbottabad and Mansehra Districts. Temperatures in southern Pakhtunkhwa are extremely hot; Dera Ismail Khan in the southernmost district of the province is known as one of the hottest places in the world with temperatures reaching to 50 °C (122 °F). In the cooler months, nights can be cold and frosts remain frequent; snow is very rare, and daytime temperatures remain comfortably warm with abundant sunshine.
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Climate of Federally Administered Tribal Areas: FATA lies on the cusp of two major climatic systems, the Monsoon to the east and the Mediterranean towards the west. Most parts of FATA are arid and semi-arid, with warm summers and cool winters, although some areas in the Kurram and Orakzai agencies fall within the humid and sub- humid zone. The pattern and character of summer and winter rainfall is intermixed to such an extent that it is difficult to determine which is dominant. Annual rainfall in the area varies dramatically, from 630 millimetres reported in Kurram during 2001-02, to just 88 millimetres in neighbouring Khyber Agency during the same year.
1.1.3. Demography Ranking 135th on the United Nation’s Human Development Index, Pakistan has a population exceeding 184 million1. Key demographic indicators are shown in table 1. During 1950–2011, Pakistan's urban population expanded over sevenfold, while the total population increased by over fourfold. About two-thirds (63.7%) of the population is rural. Approximately 23% of the population lives below the international poverty line of US$1.25 a day2. Pakistan has a multicultural and multi-ethnic society and hosts one of the largest refugee populations in the world with approximately 750,0003 Internally Displaced Persons (IDPs) and 800,0004 refugees settled across the country.
Table 1: Demographic Indicators of Pakistan
Surveyed Provinces/ Region Indicators National5 Balochistan KP FATA Sindh Total Population 184.5 9.8 24 3.8 43 (Million) Population density 231 26 187 116.7 216.02 (per Sq.Km)
Geographic Area 796,095 347,190 74, 521 27,220 140,914 (Sq.Km)
Average 6.41 8.53 7.22 9.3 6.55 Household size 6 Children under 5 13.5% 16.6% 13.6% - 13.2% years
1 Pakistan Bureau of Statistics: Year Book 2011 2 State of World’s Children Report, UNCIEF 2009. 3 WHO, June 16th 2010 4 UNHCR, June 2010 5 Pakistan Demograhpic Health Survey 2012-13 6 Household Integrated Economic Survey, 2011-12
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1.2. HEALTH CARE IN PAKISTAN
1.2.1. Health Profile The health profile of Pakistan is characterized by high population growth rate, high infant and child mortality rate, high maternal mortality ratio, and a dual burden of communicable and non-communicable diseases. Malnutrition, diarrhea, acute respiratory illness, other communicable and vaccine preventable diseases are mainly responsible for a high burden of infant and perinatal mortality, while high maternal mortality is mostly attributed to a high fertility rate, low skilled birth attendance rate, illiteracy, malnutrition and insufficient access to emergency obstetric care services (table 2). In terms of health status, Pakistan faces a double burden of disease: a rapidly increasing incidence of non-communicable diseases (NCDs) and injuries, superimposed on endemic communicable diseases (CDs). The overall burden of mortality by major category is as follows: communicable diseases 38%; maternal and perinatal mortality 15%; injuries 11%; nutritional and endocrine 7%, NCD 24% and childhood 5%. This pattern implies that the population health status is at a relatively early stage of epidemiological transition. Major factors associated with the poor health status of Pakistan are: poverty, low educational level, low status of women, inadequate sanitation and water supplies to the population and poor quality of health services7. Overall health outcomes in Pakistan are low versus other South Asian countries. Some of the factors that account for the slow progress are higher population growth rate at 2.0% in 2013, a much higher than anywhere else in South Asia. Life expectancy in Pakistan is 65.5 years in 2012. The population growth rate is 2.0%8. According to Pakistan Demographic and Household survey 2012-13 over all fertility rate has declined from 5.4 births per women in 1986-91 to 3.8 in 2011-12 i.e. a decline of 2.6 births per women in two decades. However, Pakistan has to go a long way to meet the Millennium Development Goals (MDGs) target of 2.1 births per women. Literacy remains higher in urban areas (71%) than in rural areas (49%) and more in men (69%) compared to women (44%)9. About 51% girls are enrolled in primary school as compared to 60% boys. Of those enrolled, two-thirds of girls and almost half of boys do not complete primary schooling. The majority of women (56%) are illiterate and the proportion goes up to 93% in the Federally Administered Tribal Areas10.
7 Assessment of Health Status and trends in Pakistan Draft Report AKU, 2001 8 Pakistan Economic Survey 2012-13 9 Economic Survey of Pakistan 2008-09; Chapter 10 on Education. 10 http://www.unicef.org/infobycountry/pakistan_pakistan_background.html
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Table 2: Key Health Indicators of Pakistan Surveyed Provinces/ Region Indicators National Balochistan KP FATA Sindh Maternal 272/100,000 785/100,000 275/100,000 380/100,000 314/100,000 mortality Live Births Live Births Live Births Live Births Live Births Neonatal 55/1000 63/1000 41/1000 Live 54/1000 - mortality Live Births Live Births Births Live Births Under 5 child 89/1000 111/1000 70/1000 Live 93/1000 - mortality Live Births Live Births Births Live Births 3.8 4.2 3.9 3.9 Children/ Total fertility Children/ Children/ - Children / Women Women Women women Pakistan has registered a significant decline in child and maternal mortality rates since 1990, through coverage of essential intervention to combat major diseases like malaria, measles and HIV etc. However, slow progress in indicators of maternal health and child mortality are major concerns in the progress towards MDGs. Special efforts would be required to meet the MDGs deadline of reducing infant mortality rate to 40, under 5 mortality rate to 50 and maternal mortality rate to 140 by 2015.
1.2.2. Health Systems Constitutionally health is a provincial subject but health care delivery has traditionally been jointly administered by the federal and provincial governments with districts mainly responsible for implementation. Service delivery is being organized through preventive, promotive, curative and rehabilitative services. The curative and rehabilitative services are provided mainly at the secondary and tertiary care facilities. Preventive and promotive services are mainly provided through the national programs and community health workers’ interfacing with the communities through primary healthcare facilities and outreach activities. Pakistan has one of the largest public sector owned service delivery infrastructures in the world. The health systems consist of public and private sectors. The private sector provides coverage to about 80% of the population, while public sector provides health services to the remaining 20% population of the country. Under the constitution of Pakistan, health is primarily the responsibility of the provincial governments, except the Federally Administered tribal Areas (FATA). The federal government is responsible for planning and policy formulation. Pakistan Health Care Delivery System works as an integrated health complex that is administratively managed at district level. The healthcare delivery is provided through a three-tiered health care delivery system and a range of public health interventions. The former includes Basic Health Units (BHUs) and Rural Health Centres (RHCs) forming the core of the primary health care structure. Secondary care including first and second referral facilities provides acute ambulatory and inpatient care through Tehsil Headquarter Hospitals (THQs) and District Headquarter Hospitals (DHQs) which are supported by tertiary care from teaching hospitals. 5
Basic health units serve 10,000- 15000 population and about 5-10 BHUs are linked to a Rural Health Centre (RHC) serving 25000-50,000 populations. Tehsil/Taluka hospitals (THQs) and District Headquarter hospitals (DHQs) provide secondary care services to 100000-300,000 and 1-2 million persons respectively. Maternal and child Health Centres (MNCHs) are also a part of the integrated health system, however the number of MNCHs remains limited. The MNCHs, BHUs and RHCs are primary level care facilities. BHUs are required to provide first level curative, MCH, family planning and preventive services through doctors and paramedics. Rural Health Centers provide more extensive outpatient services and some inpatient services, usually limited to short term observation and treatment of patients who are not expected to require transfer to a higher level facility. They have a staff of about 30 people including 2 male medical officers, 1 female medical officer, 1 dental surgeon and few paramedics. The THQ and DHQ hospitals have specialists and they serve as referral centres. They have 40-60 beds and appropriate support services including X-ray, laboratory and surgical facilities. The staff includes at least three specialists: an obstetrician & gynecologist, a pediatrician and a general surgeon. District Headquarters Hospitals has about 100-150 beds with at least 8 specialists including obstetrician and anesthetist. Tertiary care facilities including teaching hospitals provide curative services and to a limited extent some preventive services. There are 30 tertiary care hospitals all over the country including teaching hospitals, which are under the administrative jurisdiction of the provinces. Throughout the country the vast network of health care facilities include 972 hospitals, 5374 BHUs and sub district centres, 560 RHCs, 4842 dispensaries and 909 MCH Centres7. There has been a gradual increase in the number of doctors, dentists, nurses and lady health workers (LHWs) over the years. The 2012-13 figures showed the number of doctors in the health facilities to be around 160,298, dentists 12,544, nurses 82,119 and LHVs 13,678. The current ratio of population density to health facilities is 1,127 persons to one doctor, 14,406 for a dentist and one hospital bed for 1,786 persons6. Despite the existing strong healthcare infrastructure, the utilization of public sector health care facilities remains low due to inadequate financing, lack of resources and structural management. The country spends only 0.5-0.6% of its GDP on health. To address this issue government introduced a devolution plan in 2000 to reform all social sectors, including health. Following this plan, administrative and financial powers were transferred to districts of all provinces through an ordinance in 2001 thus making the districts a dominant level of decision making. The key idea behind this devolution of healthcare sector was to enhance district level financial and management authority to improve service delivery and increase health care utilization at grass root level. Contracting of Primary Health Care Services to non-government organizations, in the recent years has been experimented as an approach to ensure delivery of comprehensive health care services in an efficient and effective manner. This approach has generally been found successful.
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To encounter the post devolution fragmentation of health in Pakistan, the government has consolidated all key health institutions and health related functions under the Ministry of National Health Services, Regulation and Coordination (NHSRC). This ministry has two functions: regulation and coordinating which are in line with the spirit of the 18th amendment.
1.3. MALARIA IN PAKISTAN 1.3.1. Overview Malaria is a major public health problem in Pakistan. With an estimated burden of 1.6 million cases annually, Pakistan has been categorized by WHO to lie in Group-3 countries of the Eastern Mediterranean Region (countries with highest malaria burden) along with Sudan, Afghanistan and Yemen. These four countries contribute 98% of confirmed malaria cases in the region. Mass population movements within the country and across international borders (Iran and Afghanistan), natural disasters and civil unrest, unpredictable transmission patterns due to climatic changes, poor socioeconomic conditions, declining health infrastructure, resource constraints, poor access to preventive and curative services and lack of monitoring drug resistance in parasites and insecticide resistance in vectors has contributed in making malaria a public health problem. Malaria is typically unstable in Pakistan and almost all age groups are at risk of acquiring the infection. However, children below 5 years of age and pregnant women are at higher risk of infection. In Pakistan malaria transmission is seasonal, with peaks around September for vivax malaria and October for falciparum malaria. Because P vivax forms a latent liver stage, there is a peak seen in early summer (April) which may be due to relapse resulting from transmission in the previous year.
1.3.2. Malaria Vectors In Pakistan over 22 species and sub species of Anopheles mosquito have been recorded, out of which only two; A culicifacies and A. stephensi are the primary vectors involved in the transmission of malaria. Earlier studies considered A culicifacies as the most important vector in rural areas11,12 and A. stephensi in the urban areas13. This needs further evaluation as a study conducted in Punjab in 1989 reported A. stephensi to be the common species in the rural areas of Punjab.
Both the primary vectors A. culicifacies and A. stephensi are essentially endophilic in their diurnal resting habits, breed in clean water and are chiefly zoophilic. Both species
11 Mehmood F and MacDonald, B.M. Ecology of malaria transmission and vectorial capacity of Anopheles culicifacies species A in rural Punjab, Pakistan. Pakistan Journal of Medical Research, 24(2): 95-106) 1985 12 Pervez, S.D. and Shah, I.H. Role of Anopheles stephensi as malaria vector in rural areas of Pakistan. Pakistan Journal of Health, 26:73-84, 1989 13 Rehman, M and Muttalib, A. Determination of malaria transmission in central part of Karachi city; incrimination of Anopheles stephensi as the vector. Pakistan Journal of Health, 17: 73-84, 1967 7 bite from around mid-night till 2:30 am. Seasonal variation shows A. culicifacies in the country throughout the year with seasonal fluctuations in the population abundance depending upon climate. In Punjab and Sindh this species exhibit a bimodal pattern with two peaks, one in April and May and other in August and September. In cooler areas of KPK, Balochistan and Azad Jammu and Kashmir it exhibits a unimodal pattern from May till September with no clear peak. A. stephensi on the other hand starts building up populations by the end of March, reaching a peak in April-May and thereafter shows a fall from September to November. In KPK, Balochistan and AJK this species is prominent from July to September.
1.3.3. Malaria Burden Certain areas of Sindh and Balochistan have year round transmission with falciparum predominance. Table 3 shows statistics for the year 201214. The annual parasite incidence varies widely between provinces ranging from as low as 0.10 cases per 1000 population in AJK to 7.82 per 1000 population in Balochistan and 6.82 cases per 1000 population in FATA. The aggregate number of malaria cases reported from all provinces and AJK is 0.28 million. It is generally believed that public sector health facilities only reach 20% of the population while private sectors caters for the rest 80% therefore, it is estimated that the total number of malaria cases in the country could be five times higher. Applying these estimates to the 2012 data, the number could be 1.4 million cases (0.28 X 5 = 1.4) Table 3: Malaria Statistics Pakistan - 2012
TOTAL Indicators Province Population Slides/RDT Positive P.V PF Mix SPR API % P.F Examined 17,52 Punjab 91,943,208 1,636,079 16,426 1008 88 1.07 0.19 5.75 2
Sindh 39,231,406 1,785,499 114,651 79,511 31,083 4057 5.56 2.9 27.1
63,49 KPK 22,985,802 534,516 57,402 5804 288 12.4 2.76 9.14 4 29,92 FATA 4,382,727 197,571 26,432 3232 262 16.2 6.82 10.79 6 63,73 Balochistan 8,295,628 588,558 35,372 28,248 113 12.85 7.68 44.32 3
AJK 4,160,025 146,744 433 421 11 1 0.29 0.10 2.54 4809 National 170,998,796 4,888,967 289,759 215,564 69,386 5.57 1.69 23.9 (1.6)
14 DOMC Annual Surveillance Data 2012
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Table 3 shows that the proportion of P. falciparum varies from 2.5% - 44.3% in different provinces including AJK with maximum cases (44.3%) reported from Balochistan followed by Sindh (27%). In 2012 the overall PV to PV ratio was 74:24 (Fig1)
Figure 1: Overall PV-PF Ratio (2008-12) in Pakistan
90 76.5 80 72.5 74.4 70 64.5 61.7 60 PV 50 38.3 PF 40 36 33 Mix 27.5 Percentage 30 23.5 23.9 20
10 2.5 0.004 1.06 1.65 0 2008 2009 2010 2011 2012
The MIS data 2008-2012 obtained from Directorate of Malaria, Pakistan includes all four provinces and Regions (Punjab, Sindh, Balochistan, KPK and FATA and AJK). The data shows that Plasmodium falciparum and Plasmodium vivax are the prevalent species in Pakistan and are constantly on rise since 2008. The P. vivax and P. falciparum both showed a sharp rise in 2010 probably due to intensive floods all over Pakistan in this year. The number of Plasmodium vivax is on a rise since 2010 while, falciparum has shown a decline this year (Figure 2). Data of mixed infection is available since 2009 and it also shows a rise.
Figure 2: Malaria parasite trends (2007-12)
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Figure 3 shows Annual Parasite incidence (API), Slide Positivity Rate (SPR) and Blood Examination Rate (BER) trend over time. The API has shown an upward trend from 2009-2010 with a marginal descend in the subsequent years which coincides with BER. There has been an increase in SPR from 2009 to 2011 with a decline in 2012.
Figure 3: Trends in malaria indicators Pakistan (2007-12)
1.3.4. Malaria Control Pakistan- Global Fund Support The Government of Pakistan is implementing Malaria Control Program in 72 malaria endemic districts with its own resources while in 19 highly endemic districts; this activity was supported from the Global Fund (Round 7). Pakistan also received the Global Fund (Round 10) Malaria grant targeting 38 highly endemic districts. These 38 target districts include 19 districts of the Global Fund Round 7 and additional 19 districts for Round 10. The total target population living in these districts is estimated at 24.84 million people.
The aim of the malaria control programme is to reduce the burden of disease in these 38 high risk districts by scaling-up appropriate intervention including strengthening case management, treating all confirmed malaria cases as per national guidelines and vector control through IRS and LLINs. In order to achieve the targets the programme requires bench mark against which progress towards scale-up can be measured.
Figure 4 shows API from 2009-2012 in 38 GF high risk distrcits of Pakistan. There is an increase in API from 7.13/1000 population in 2009 to 10.31/1000 in 2010 followed by a decline in 2012 (API 7.8/1000). Descend in the API in last year is indicative of better programme performance.
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Figure 4: Annual Parasite Incidence per 1000 Population (2009-12)
1.4. MALARIA CONTROL OBJECTIVES AND INDICATORS FOR GF SUPPORTED DISTRICTS
1.4.1. Objectives 1. To enhance access of population at risk to quality assured early diagnosis and prompt treatment services. 2. To scale-up multiple prevention interventions especially LLINs and IRS to the level of universal coverage in target population. 3. To enhance technical and management capacity of malaria control program for improved planning, management and monitoring of malaria control interventions. 4. To improve health seeking behaviors and practices of target communities in highly mmalaria endemic districts through enhanced community awareness and participation.
1.4.2. Indicators (GF Round 7 & 10)
A. Impact indicator
1. Annual Parasite Incidence (API): Number of confirmed malaria cases detected per 1000 persons during 01 year of targeted population in 38 target districts (R 7 & 10)
2. Slide positivity rate (SPR): people found positive in slide testing among all slides taken in 19 new target districts (Round-10)
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3. Percentage of malaria (confirmed) admissions among all hospital admissions (Round 7)
B. Outcome Indicators 1. Percentage of people with uncomplicated or severe malaria receiving antimalarial treatment according to national guidelines in the target districts (R- 7 & 10) 2. Percentage of population in target areas sprayed with indoor residual spraying in the last 12 months in target districts (R-7 & 10) 3. Percentage of households with at least one LLIN in target districts (R-7 & 10) 4. Percentage of children younger than 5 years of age who slept under LLIN the previous night (R-7 & 10) 5. Percentage of people who know the cause of, symptoms of, and preventive measures for malaria in 38 highly endemic districts (R-7 & 10)
C. Output Indicators 1. Number and percentage of health facilities in the target districts with microscopy and/or rapid diagnostic testing capability (R-7 & 10) 2. Number of RDTs done and read in target districts (R-7 & 10) 3. Number of health providers trained on malaria diagnosis (microscopy and RDT) and QA in target districts (Round-10) 4. Number of health care providers trained on national case management guidelines, LLIN distribution, Vector Control and Medical Entomology in target districts (Round 7&10) 5. Percentage of lab/RDT confirmed P. falciparum malaria cases correctly treated as per national guidelines in target districts(R-7 & 10) 6. Number of LLINs distributed to people in target districts (R 10) 7. Number of LLINs distributed for women (15 to 49 years) and children under 5 years of age in target districts (Round-7) 8. Number of households (or structures or walls) in target districts sprayed by indoor residual spraying in the last 12 months (R-7 & 10) 9. Number of health personnel trained on malaria data management, M&E and early detection of malaria outbreaks (R-7 & 10)
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10. Percentage of monitoring visits conducted versus planned in target districts (R-7 & 10) 11. Number of people reached by behavior change communication community outreach in target districts (R-10)
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2.
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2. PAKISTAN MALARIA INDICATOR SURVEY
2.1. RATIONALE OF MALARIA INDICATOR SURVEY The malaria control programme plans to reduce the burden of disease in 38 high risk districts by scaling-up appropriate interventions including strengthening case management, treating all confirmed malaria cases as per national guidelines and vector control through IRS and LLINs. To achieve its targets, the programme requires bench mark against which progress towards scale-up can be measured. To provide the necessary bench mark (baseline information), the program with the support of GFATM and the technical assistance from WHO planned a malariometeric survey in 38 high risk malaria districts. The survey was awarded to Pakistan Medical Research Council through open bidding.
2.2. SURVEY OBJECTIVES Objective-1: To collect data to monitor the implementation of the Global Fund Round 10 Malaria Grant. Related Research Questions 1.1. What are the inputs (trainings, Combo RDT kits, microscopes, reagents and supplies, antimalarials, distribution of LLINs, guidelines and print material etc.), processes (diagnosis, treatment, prevention, community mobilization) for implementation of GF-10 & GF-7 activities in 38 districts of Balochistan, KPK, FATA/FRs and Sindh provinces of Pakistan? 1.2. What are the outputs (suspected and confirmed malaria cases, antimalarial courses given to suspected, confirmed and complicated malaria cases) and outcomes (reduction in malaria incidence with GF inputs) achieved through implementation of GF-10 & 7 interventions? 1.3. What are the reasons for the gaps, if any at central, district and facility level in the implementation process in GF R-10 & 7 districts? Objective-2: To measure the malaria parasite prevalence examined through microscopy and rapid diagnostic tests among all age groups in 19 districts of Global Fund Round 10. Related Research Questions 2.1. What is the prevalence of fever (last 72 hours) in the selected households? 2.2. What is the prevalence of malarial parasites (P falciparum and P vivax) in the general population (in all age groups including pregnant women) through microscopy and all febrile cases on RDTs?
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Objective-3: To collect baseline information regarding people’s knowledge about the cause, symptoms, and preventive measures for malaria in all 38 districts (R- 10 & R-7) Related Research Questions 3.1. What is the level of knowledge about, symptoms and treatment of malaria in general population? 3.2. What are the treatment seeking practices (self-treatment, community based i.e. LHWs, public sector health facilities, general practitioners and others) among general population. 3.3. What is the knowledge regarding use of bednets (LLINs/untreated nets) in the general population? 3.4. What are the practices for using bednets (LLINs/untreated nets) in general population and specifically in children below 5 years of age and pregnant women? 3.5. What is the level of knowledge, perceptions and experience of general population regarding use of indoor residual spraying (IRS)? Objective-4: To collect data that will be used for identification of high-risk population pockets for implementation of specific malaria prevention interventions (LLINs and IRS) in 19 districts of Round-10. Related Research Questions 4.1. What are the malaria trends (parasite prevalence), geographic distribution (mapping the high-risk population pockets) and catchment public sector health facilities in the general population, which could be prioritized for LLIN and IRS? 4.2. What are the strategic options and recommendations for the orientation of malaria control programmes based on malaria indicator survey?
2.3. ETHICAL APPROVAL AND CONSENT An ethical approval was obtained from the National Bioethics Committee and survey instruments were translated in easy Urdu (National language) for wider acceptability and usage.
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2.4. SURVEY METHODOLOGY 2.4.1. Study Design and Approach
2.4.1.1. Design This was a two stage random cluster, cross-sectional, malaria indicator survey meant to inform, GF-10 & 7 implementation status, malaria parasite prevalence (in 19 Round 10 districts), knowledge and practice regarding, treatment seeking behaviour and prevention (All 38 districts of GF-10 & 7) and identification of high risk population pockets (in 19 districts of Round-10). The survey was conducted between September and November 2013.
2.4.1.2. Settings: The survey was conducted in 38 target districts of GF-10 & 7 including Balochistan (15), KPK (7), FATA & FR (10) and Sindh (06) provinces of Pakistan. The study covered mainly the households (all age groups and both genders), catchment health facilities (public sector) mainly rural areas.
2.4.1.3. Sampling frame and sample size The sample size was calculated in consultation with a former expert from Federal Bureau of Statistics for 38 GF Round 10 & 7 districts. The entire population of all 38 districts of Sindh, Balochistan, KPK and FATA were treated as universe for this survey.
2.4.1.4. Stratification: Inspite of rural dominance, each district was stratified according to urban and rural population; however, all seven agencies in FATA were 100% rural therefore, there was no separate stratification in these areas. In other provinces also most UCs were in the rural areas therefore the survey covered pre-dominantly the rural population and to some extent peri-urban.
2.4.1.5. Sampling Frame: List of Union Councils (UCs) in each district was used as sampling frame for selection of sample UCs.
2.4.1.6. Sample Design: A two stage sample design was adopted for this survey. At first stage sample UCs were selected using probability proportionate size (PPS) method of selection from a stratum.
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At second stage a cluster of 50 households were selected randomly from the sample UC for enumeration. a) Sample Size: The survey was planned to provide reliable estimates for the districts. To assess the disease prevalence, blood tests were carried out on the selected population of 19 districts of GF-10. Since no information at district level was available therefore, the DOMC reported prevalence at provincial level and the provincial estimates were used to determine the sample size. Keeping in view the above, a sample size of 11,100 households was estimated for 38 districts. Cluster approach was used to enumerate and undertake blood testing of the population. Generally, for the surveys where events are not uniformly distributed and their prevalence is not so high, cluster technique is considered as most appropriate. A cluster of 50 houses was therefore taken for this survey. Most surveys on health and demography in Pakistan follow more or less the same cluster size. In 19 districts of GF-10, there were 111 clusters of 50 households each that covered about 41000 persons. The sample in remaining 19 districts of GF-7 was also 111 clusters of 50 households each that covered about 41000 persons, making a total of 82,000 persons. All union council/clusters and households were randomly selected in each district. For the selection of health facilities all district hospitals and one tehsil /taluka hospital was assessed from each of the 19 GF R-10 and 19 GF R-7 districts. For the selection of the primary health care centres, the clusters in each district were randomized to have at least 1 RHCs and 4 BHUs making a total of 05 PHC health facilities per district. List of 38 districts is shown in table 4.
2.4.2. Data Collection
2.4.2.1. Survey instruments The survey instruments included household questionnaire that was adapted from WHO, Roll Back Malaria-Monitoring and Evaluation Reference Group15. In addition health facility assessment tool was also developed. These instruments were finalized through a
15 Roll Back Malaria, MEASURE Evaluation, World Health Organization, and United Nations Children’s Fund. 2004. Guidelines for core population coverage indicators for Roll Back Malaria: To be obtained from household surveys. Calverton, Maryland: MEASURE Evaluation.
18 consultative process involving all stakeholders including Directorate of Malaria Control, WHO, Save the Children and malaria control experts. The household questionnaire was used to list all members of the selected households. Basic characteristics of each person were collected including age, gender and head of household. Key malaria-specific issues covered in the household questionnaire included:
Demographic information including household characteristics.
Coverage by Indoor residual spraying (IRS) and long lasting Insecticide-treated mosquito nets (LLINs).
Knowledge Attitude and Practices about: o Treatment seeking behaviour o Malaria prevention The health facility questionnaire (Annexed as Appendix D) was used to collect information on;
Malaria case notification from each selected health facility.
Utilization of RDTs and positivity rate for P.vivax and P.falciparum.
Utilization of microscopy and rate of malaria confirmed case from health facility registers (FM1, FM2, and FM3).
Knowledge and practices of the doctors and paramedics,
Availability of supplies including anti-malarial drugs, RDTs, microscopes, reagents and print materials and monitoring and quality control arrangements.
2.4.2.2. Data collection methods a) Finalizing survey plan: A core survey team (PI, Co.PI, Survey Coordinators and other team members) visited the provinces to finalize the survey plan. The survey was executed in 38 districts (Table 4).
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Table 4: List of 38 Highly Malaria Endemic Districts in Pakistan
Province R-7 Districts R-10 Districts
Mithi/Tharparkar Tando Allahyar
Khairpur Mirpurkhas SINDH Thatta
Dadu Zhob/Sheran Panjgur Noushki Kharan Gawadar Chagi Kech Washuk BALOCHISTAN Sibi/Harnai Pishin Qilla Saifullah Musakhel Nasirabad Loralai Mastung Lakki Marwat Tank Bannu Charsadda KPK Mardan Nowshera Dera Ismail Khan Kurram North Waziristan Khyber Orakzai Bajaur Mohmand FATA South Waziristan FR Peshawar/Kohat
FR Bannu/Lakki FR Tank/DI Khan
TOTAL 19 19
GRAND TOTAL 38
20 b) Field Team composition: The field team was supervised by the core team members who acted as Regional Coordinators for Balochistan, KPK/FATA and Sindh provinces (Table 5).
Table 5: Field team composition in each district
S.# Composition Number of persons Total persons
1. District Coordinator (preferably 01 per district 1 x 38 = 38 Medical Officer) persons
2. Male Interviewer (preferably from 01 per district 1 x 38 = 38 health/malaria back ground) persons
3. Female Interviewer (preferably 01 per district 1 x 38 = 38 from health/malaria back ground) persons
01 per district 1 x 19 = 19 4. Microscopist (19 districts of GF=10) persons 2 x 38 = 76 5. Enumerators 02 per district persons c) Hiring of field teams. The district Coordinators were identified and hired for a short period in consultation with the Provincial MCPs and EDOs Health of the target districts. Regional/District Coordinator selected the data collection team (male and female interviewers) and microscopist in consultation with the EDO Health. The provincial/district trained persons acted as enumerators. d) Piloting of instruments: The survey instruments finalized in consultation with the stake holders were field tested in KPK, reviewed, refined, coded and printed. e) Training: The provincial and district survey coordinators, enumerators and survey team members (data collectors) were trained in their respective provinces (i.e. Balochistan, KPK and Sindh/districts) on survey instruments and tools using standardized survey manual. All participants received standard training to fill questionnaires and perform finger pricks for testing blood on RDTs and making blood smears for microscopy in the field. They were also trained on staining blood slides. f) Identification of clusters (UCs) and listing of households: A team of 2 enumerators and one supervisor visited the identified UC and prepared a list of 250-300 houses
21 following standard methodology for enumeration of houses. Later 50 houses were selected randomly from the already enumerated 250-300 houses. All heads of the households of these houses were informed by the team about the malaria survey and requested for their voluntary participation. A specially designed consent form was used to inform the participants about the nature and purpose of the survey and also to take consent. g) Community sensitization: To have maximum participation from the community, community sensitization was done with the village elders and the decision makers through discussions, flyers and meetings at the district and local level. h) Household data collection: The survey was conducted between September and November 2013. Survey team in each cluster/UC approached the head of the household and took informed written consent from them to initiate interviews and take blood samples. One household form was filled by the team member through the help of the head of the household. This form, collected information about the age, gender and other basic demographic information on all members living in that house. The team later filled the individual questionnaire form all household members who were present at the time of interview to gather information on knowledge and treatment practices about malaria. All household members (in Round-10 districts only), irrespective of age and gender also underwent blood microscopy (thick and thin slides). RDTs were done only in cases that either suffered from fever in the last 72 hours or were suffering from fever at the time of interview. Fever was measured using a thermometer. For finger prick disposable lancets and swabs were used for each individual while, the phlebotomist wore latex gloves to protect himself. After the finger prick, the first drop of blood was wiped off, the second drop was used to prepare a thick/ thin blood film and the third drop if needed was applied to the RDT. All RDTs were read on spot and results entered in the report form and handed over to the patients, irrespective of the results. All RDT positive cases were referred to the nearest health facility for treatment, using a specially designed referral form. All used lancets, gloves, swabs etc. were placed in sharp container and disposed accordingly. Microscopy slides were air dried and labelled with name of the person and their respective identity number and placed in a slide box which was marked with the ID of the district and name of UC. Both RDTs and microscopy slides along with the completed household questionnaires were placed in a polythene bag and sent to district coordinator on completion of a UC. A trained microscopist at the district level stained all the slides and examined them. The District Coordinator entered the microscopy results in the individual record from. All positive and 10% randomly selected negative slides 22 were sent to the designated provincial reference laboratories for quality assurance. The Provincial Coordinators/ team leader monitored and examined the quality of data collected by randomly selecting 5% household questionnaires and some health facilities. i) Health facility data collection: The survey team (district coordinator) approached the EDO (H) to seek permission to collect data from the health facility. The data was collected on following indicators: i) malaria case notification from each selected health facility, ii) utilization of RDTs and positivity rate for P.vivax and P.falciparum, iii) utilization of microscopy and rate of malaria confirmed case from health facility register (FM1, FM2, FM3), iv) knowledge and practices of the doctors and paramedics, v) availability of supplies including anti-malarial drugs, RDTs, microscopes, reagents and print materials and vi) monitoring and quality control arrangements. j) Data collection through GIS/health mapping: Though all data was collected on paper in the form of questionnaires but for some districts and UCs, GIS health Mapper software was also used for data collection. The Health Mapper software was used to map the malaria high risk pockets on the basis of data collected. Mobile SMS service was used to monitor the data collection.
2.4.3. Data Management and Analysis Statistical software SPSS ver. 19.0 was used for data feeding and analysis. A double data entry method was adopted. Data from the houses and the health facilities were collected on structured pre-tested questionnaire/forms containing both open and close- ended questions, these questionnaire/forms were transported to PMRC Islamabad for data entry and analysis. Three day workshop “hands on training of filled questionnaires/forms and data entry format in SPSS” conducted for computer operator before the start of data entry process in SPSS. The results were given in number and percentages for different variables (province, districts, union council, malaria related information of household members i.e. gender, age group, marital status, women pregnancy status of married women, fever, results of RDTs/ microscopy malaria knowledge from ≥15 years age, demographic information of household, malaria related mortality, KAP about personal protection and treatment seeking behavior. Information for health facility i.e. staff position, equipment and supplies, availability of anti-malarial drugs, case management, diagnosis, treatment of complicated malaria, LLINs, guidelines, training and malaria situation in the year 2012 and 2013 were computed in descriptive analysis.
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3.
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3. HOUSEHOLD POPULATION AND CHARACTERISTICS
This chapter presents the findings on household population, including demographic information on household characteristics and members including age, gender, household size, pregnant women and household possessions. For this survey, a household was defined as a “person or group of related and unrelated persons who lived together in the same dwelling unit(s) or in connected premises, who acknowledged one adult member as head of the household and who had a common arrangement for cooking”.
3.1. HOUSEHOLDS ACCESSED AND RESPONSE A total of 11,100 households were selected for 38 high risk districts. Of these 5550 households each were selected for 19 districts of Round 7 and Round-10. During the survey almost 98.2% houses were visited and their head of the households were interviewed (Table 6). To assess the knowledge, attitude and practices about malaria, all members of the household 15 years and above were also individually interviewed. This comprised of 32,008 persons yielding a response rate of 82%. The main reason for non response was their absence from home (15%). These individuals could not be located despite a visit in the evening of the same day or the next day. About 3% persons refused to participate. Table 6: Number of households, number of interviews and response rates
Target Accessed/surveyed District Response Household Household
19 districts of Round-07 5550 5559 100
19 districts of Round-10 5550 5345 96.2
38 districts 11100 10904 98.2
Interviews with household Eligible Interviewed Response members Individuals
32008 82%
Age 15 years above 39126 5802 Absent 15%
1316 Refused 3%
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Table 7 shows that in almost 72% houses, the head of the household was a male and in only 28.2% it was a female. Of the female respondents, the lowest proportion of female respondents (9.2%) was from FATA Region.
Table 7: Head of household by gender in 38 districts
Male Female Head of Province Districts Household Nos. % Nos. %
6 districts 2081 1325 63.7 756 36.3 Sindh 4 districts (R-07) 1390 1083 77.9 307 22.1
2 districts (R-10) 691 242 35.0 449 65.0
15 districts 3728 2543 68.2 1185 31.8 Balochistan 9 districts (R-07) 2220 1209 54.5 1011 45.5
6 districts (R-10) 1508 1334 88.5 174 11.5
7 districts 2500 1610 64.4 890 35.6 KPK 3 districts (R-07) 1049 480 45.8 569 54.2
4 districts (R-10) 1451 1130 77.9 321 22.1
10 districts 2595 2356 90.8 239 9.2 FATA 3 districts (R-07) 900 899 99.9 1 0.1
7 districts (R-10) 1695 1457 86.0 238 14.0
38 districts 10,094 7834 71.8 3070 28.2 Total 19 districts (R-07) 5559 3671 66.0 1888 34.0
19 districts (R-10) 5324 4164 78.2 1160 21.8
The age of the respondents is shown in table 8. Majority of the respondents (73.5%) were between 15-49 years, while 25% were of 50 years or over.
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Table 8: Age of the respondents by Province
15-49 years 50 & above Province Districts Individuals Nos. % Nos. % 6 districts Sindh 2078 1550 74.6 524 25.2 4 districts (R-07) 1390 955 68.7 432 31.1
2 districts (R-10) 688 595 86.5 92 13.4 15 districts Balochistan 3711 2646 71.3 926 25.0 9 districts (R-07) 2220 1649 74.3 555 25.0
6 districts (R-10) 1491 997 66.9 371 24.9 7 districts KPK 2499 1784 71.4 699 28.0 3 districts (R-07) 1049 801 76.4 245 23.4
4 districts (R-10) 1450 983 67.8 454 31.3 10 districts FATA 2595 2020 77.8 562 21.7 3 districts (R-07) 900 697 77.4 203 22.6
7 districts (R-10) 1695 1323 78.1 359 21.2 38 districts Total 10,883 8000 73.5 2711 24.9 19 districts (R-07) 5559 4102 73.8 1435 25.8
19 districts (R-10) 5324 3898 73.2 1276 24.0 Age not known in 193 households
3.2. HOUSEHOLD POPULATION BY SIZE, AGE AND GENDER The average household size was 6.2 persons and male to female ratio was 1.2:1. The proportion of males was higher (1.4:1) in FATA (Table 9). Table 10 shows the distribution of household population by age and gender. Out of 67,921 individuals, 53.6% were males and 46.4% females. Almost 42.3% population was under 15 years and 13.0% under 5 years of age. Age was not known in 50 individuals.
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Table 9: Households size and gender distribution by Province
Average
Province Districts Household Individuals Household M : F ratio size 6 districts 2081 12229 5.9 1.1 : 1 Sindh 4 districts (R-07)
1390 8630
2 districts (R-10) 691 3599 15 districts 3728 22464 6 1.1 : 1 Balochistan 9 districts (R-07)
2220 14334
6 districts (R-10) 1508 8130 7 districts 2500 16701 6.7 1 : 1 KPK 3 districts (R-07)
1049 7429
4 districts (R-10) 1451 9272 10 districts 2595 16577 6.4 1.4 : 1 FATA 3 districts (R-07)
900 6260
7 districts (R-10) 1695 10317 38 districts 10904 67971 6.2 1.2 : 1 19 districts (R-07) Total 5559 36653 19 districts (R-10) 5345 31318
Table 10: Population by age and gender in 38 districts
Male Female Total Age in years Nos. % Nos. % Nos. % Under 5 4516 12.4 4336 13.7 8852 13.0
5 – 14 10865 29.9 9078 28.8 19943 29.3
15 – 49 17514 48.3 15764 50.1 33278 49.0
50 & above 3473 9.5 2375 7.5 5848 8.6
Total 36368 53.6 31553 46.4 67921 100.0 (Age not known in 50 individuals)
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3.3. AGE PYRAMID OF THE POPULATION Figure 6 illustrates the age distribution among the population surveyed. The age structure showed a typical pyramid picture with a wider and larger youth population making the base of the pyramid and narrow elderly group.
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3.4. PREGNANT WOMEN BY AGE Table 11 shows the age of pregnant women along with their distribution within the Provinces. At the time of survey about 6.2% women were reported as pregnant. Pregnancy rate was highest (10%) in Balochistan and lowest in KPK (4.3%) and FATA (3.7%).
Table 11: Age and number of pregnant women in 38 districts
Age 15-29 years Age 30-39 years Age 40-49 years Total
Province District Pregnant Pregnant Pregnant Pregnant Rep. Rep. Rep. Rep. Age Age Age Age Nos. % Nos. % Nos. % Nos. %
Sindh 6 districts 1628 106 6.5 718 64 8.9 537 7 1.3 2883 177 6.1 4 districts
(R-07) 1167 75 6.4 491 45 9.2 374 6 1.6 2032 126 6.2 2 districts
(R-10) 461 31 6.7 227 19 8.4 163 1 0.6 851 51 6.0 Baloch- 15 districts istan 3027 305 10.1 1428 218 15.3 825 37 4.5 5280 560 10.6 9 districts
(R-07) 1960 209 10.7 900 173 19.2 503 27 5.4 3363 409 12.2 6 districts
(R-10) 1067 96 9.0 528 45 8.5 322 10 3.1 1917 151 7.9
KPK 7 districts 2346 71 3.0 1036 45 4.3 661 2 0.3 4043 118 2.9 3 districts
(R-07) 968 23 2.4 475 13 2.7 281 1 0.4 1724 37 2.1 4 districts
(R-10) 1378 48 3.5 561 32 5.7 380 1 0.3 2319 81 3.5
FATA 10 districts 1969 87 4.4 958 35 3.7 631 8 1.3 3558 130 3.7 3 districts
(R-07) 845 52 6.2 419 15 3.6 244 5 2.0 1508 72 4.8 7 districts
(R-10) 1124 35 3.1 539 20 3.7 387 3 0.8 2050 58 2.8
Total 38 districts 8970 569 6.3 4140 362 8.7 2654 54 2.0 15,764 985 6.2 19 districts (R-07) 4940 359 7.3 2285 246 10.8 1402 39 2.8 8627 644 7.5 19 districts (R-10) 4030 210 5.2 1855 116 6.3 1252 15 1.2 7137 341 4.8
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3.5. HOUSING CHARACTERISTICS
Information on housing characteristics such as type of house, number of rooms in a house and availability of electricity is given in table 12. Almost two-third of the houses (72%) was kacha and 90% houses had electricity. Almost all (100%) households had at least one sleeping room, 63.9% had 2 sleeping rooms and 32.7% had 3 sleeping rooms. To prevent flies and mosquitoes from entering the rooms, over 50% of the houses had windows covered with some kind of screen. Separate animal houses were present in 41% households.
Table 12: Housing Characteristics in 38 districts Round-07 Round-10 Total Household 5559 5345 10904 Nos. % Nos. % Nos. % Type of house – 5374 5125 10499 Information available Kacha 3934 73.2 3629 70.8 7563 72.0 Pacca 1323 24.6 1390 27.1 2713 25.8 Mixed (Kacha & Pacca) 117 2.2 106 2.1 223 2.2 Number of rooms – 5514 5258 10772 Information available One 5514 100.0 5258 100.0 10772 100.0 Two 4212 76.4 3856 73.3 8068 74.9 Three 2760 50.1 2583 49.1 5343 49.6 Four 1764 32.0 1608 30.6 3372 31.3 Five & above 1032 18.7 953 18.1 1985 18.4 Sleeping rooms One 5514 100.0 5258 100.0 10772 100.0 Two 3580 64.9 3299 62.7 6879 63.9 Three 1833 33.2 1692 32.2 3525 32.7 Four 980 17.8 806 15.3 1786 16.6 Five & above 552 10.0 427 8.1 979 9.1 Room with screen (Jali) One 1594 28.9 952 18.1 2546 23.6 Two 1247 29.6 660 20.0 1907 27.7 Three 781 28.3 324 19.1 1105 31.3 Four 315 17.9 141 17.5 456 25.5 Five & above 197 19.1 79 18.5 276 28.2
Animal rooms 2235 40.2 2223 41.6 4458 40.9
Household have electricity 5042 90.7 4758 89.0 9800 89.9
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3.6. HOUSEHOLD POSSESSIONS Information collected on household possessions is presented in table 13. The results exhibit that at the time of survey, 51.5% of households owned a television, 86% owned a mobile phone and 28% owned a radio. Only 10.7% houses owned all three amenities i.e. TV, radio and mobile phone.
Table 13: Household Possessions (n=8724)
Round-07 Round-10 Total
Household 5559 5345 10904
Nos. % Nos. % Nos. %
Household Possessions 4404 79.2 4182 78.2 8586 78.7
Television 2399 54.5 2019 48.3 4418 51.5
Radio 1111 25.2 1288 30.8 2399 27.9
Mobile 3942 89.5 3436 82.2 7378 85.9
TV alone 240 5.4 290 6.9 530 6.2
Radio alone 76 1.7 269 6.4 345 4.0
Mobile phone alone 1539 34.9 1481 35.4 3020 35.2
TV + Radio 146 3.3 187 4.5 333 3.9
TV + Mobile 1514 34.4 1123 26.9 2637 30.7
Radio + Mobile 390 8.9 413 9.9 803 9.4
TV + Radio + Mobile 499 11.3 419 10.0 918 10.7
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4. KNOWLEDGE, ATTITUDES AND PRACTICES ON MALARIA
Current knowledge, attitude and practices about malaria were collected in the population aged 15 years and over. The key areas included knowledge about malaria, its cause and symptoms, source of information, treatment seeking behavior and preference for using government or private sector health facilities. Data were also collected on prevention practices including use of LLINs and IRS.
4.1. HEARD ABOUT MALARIA AND SOURCE OF INFORMATION Tables 14 shows the information about malaria and its sources. More than two third (81%) of the population had some information on malaria and knew about the disease. Information about malaria as a disease was maximum in Balochistan (92.5%) followed by Sindh (87.2%), KPK (70.2%) and FATA (66.6%).
Table 14: Percentage of people (≥15) who heard about malaria in 38 districts
Respondents Heard about Malaria Age Province District ≥15 Years No. % No. % 6 districts 6973 6445 92.4 5619 87.2 Sindh 4 districts (R-07) 4976 4832 97.1 4562 94.4
2 districts (R-10) 1997 1613 80.8 1057 65.5
15 districts 12831 11836 92.2 10952 92.5 Balochistan 9 districts (R-07) 8231 7610 92.5 7245 95.2
6 districts (R-10) 4600 4226 91.9 3707 87.7
7 districts 9780 6356 65.0 4463 70.2 KPK 3 districts (R-07) 4363 2622 60.1 2201 83.9
4 districts (R-10) 5417 3734 68.9 2262 60.6
10 districts 9542 7371 77.2 4909 66.6 FATA 3 districts (R-07) 3786 3257 86.0 2085 64.0
7 districts (R-10) 5756 4114 71.5 2824 68.6
38 districts 39126 32008 81.8 25943 81.1 19 districts (R-07) 21356 18321 85.8 16093 87.8 Total 19 districts (R-10) 17770 13687 77.0 9850 72.0 33
Source from where these people got this information was from family members (52.5%), health facility (52%), Electronic media (25.9%) followed by print media (14%) and LHWs (10.6%) (Table 15).
Table 15: Source of information about Malaria (15 years & above age)
Source of Information Heard Print Province District about Elect. Media Media Health Facility LHW Family member Malaria No. % No. % No. % No. % No. % 6 districts 5619 1358 24.2 270 4.8 2872 51.1 578 10.3 3066 54.6 Sindh 4 districts (R-07) 4562 996 21.8 231 5.1 2344 51.4 497 10.9 2721 59.6
2 districts (R-10) 1057 362 34.2 39 3.7 528 50.0 81 7.7 345 32.6 15 districts 10952 2908 26.6 1896 17.3 6169 56.3 1660 15.2 6114 55.8 Balochistan 9 districts (R-07) 7245 2399 33.1 1695 23.4 3619 50.0 1426 19.7 5145 71.0
6 districts (R-10) 3707 509 13.7 201 5.4 2550 68.8 234 6.3 969 26.1 7 districts 4463 1007 22.6 505 11.3 1237 27.7 168 3.8 2520 56.5 KPK 3 districts (R-07) 2201 398 18.1 236 10.7 729 33.1 122 5.5 903 41.0
4 districts (R-10) 2262 609 26.9 269 11.9 508 22.5 46 2.0 1617 71.5 10 districts 4909 1454 29.6 1161 23.7 3209 65.4 355 7.2 1910 38.9 FATA 3 districts (R-07) 2085 778 37.3 799 38.3 1702 81.6 341 16.4 812 38.9
7 districts (R-10) 2824 676 23.9 362 12.8 1507 53.4 14 0.5 1098 38.9 38 districts 25943 6727 25.9 3832 14.8 13487 52.0 2761 10.6 13610 52.5 Total 19 districts (R-07) 16093 4571 28.4 2961 18.4 8394 52.2 2386 14.8 9581 59.5
19 districts (R-10) 9850 2156 21.9 871 8.8 5093 51.7 375 3.8 4029 40.9 Source of information are cumulative number & percentage (Multiple responses)
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Table 16 shows the source of information about LLINs i.e. from where they heard about LLINs. Majority (36.7%) had heard about it from the health facility, followed by television (16.2%) and LHWs (12.9). Same pattern was observed across all provinces.
Table 16: Information about LLINs and its source Health LLIN Television LHW Province Districts Individual facility Nos % Nos % Nos % Nos %
6 districts 6142 2913 47.4 1492 24.3 959 15.6 747 12.2 Sindh 4 districts (R-07) 4758 2362 49.6 1324 27.8 724 15.2 534 11.2
2 districts (R-10) 1384 551 39.8 168 12.1 235 17.0 213 15.4
15 districts 11666 7585 65.0 5513 47.3 1998 17.1 2116 18.1 Balochistan 9 districts (R-07) 7519 5306 70.6 3690 49.1 1796 23.9 1671 22.2 6 districts (R-10) 4147 2279 55.0 1823 44.0 202 4.9 445 10.7
7 districts 5075 1594 31.4 865 17.0 724 14.3 363 7.2 KPK 3 districts (R-07) 2077 822 39.6 313 15.1 494 23.8 289 13.9 4 districts (R-10) 2998 772 25.8 552 18.4 230 7.7 74 2.5
10 districts 5023 2928 58.3 2362 47.0 830 16.5 360 7.2 FATA 3 districts (R-07) 1873 1273 68.0 1181 63.1 571 30.5 242 12.9 7 districts (R-10) 3150 1655 52.5 1181 37.5 259 8.2 118 3.7
38 districts 27906 15020 53.8 10232 36.7 4511 16.2 3586 12.9 Total 19 districts (R-07) 16227 9763 60.2 6508 40.1 3585 22.1 2736 16.9
19 districts (R-10) 11679 5257 45.0 3724 31.9 926 7.9 850 7.3
4.2. KNOWLEDGE ABOUT CAUSE, SYMPTOMS AND LETHALITY OF MALARIA
There were 25943 individuals aged 15 years and above who heard about malaria, as described in section above (Table 14). Table 17 shows that out of 23,739, who knew that malaria is caused by mosquito, 89.6% reported fever as the main symptom and 84.6% said that malaria is preventable. Similar pattern was observed across provinces.
Almost two third (79.4%) of the population knew that malaria can kill if not treated. Of those who did not know its lethality, highest were from Balochistan (74.1%) followed by KPK (72.9%). Within Balochistan, populations belonging to Nasirabad, Loralai, Chagi and in KPK, Mardan did not know that malaria can kill if it is not treated.
35
Table 17 : Percentage of people (age 15 years and above) who knew the cause, symptoms and prevention of malaria (38 GF Districts)
Malaria can Individuals Symptom -Fever Kill Prevention Province District said Malaria if not treated is Caused by Mosquito No. % No. % No. %
6 districts 5514 4945 89.7 5060 91.8 4898 88.8
Sindh 4 districts (R-07) 4480 4001 89.3 4103 91.6 3968 88.6
2 districts (R-10) 1034 944 91.3 957 92.6 930 89.9
15 districts 10500 9394 89.5 7777 74.1 9095 86.6
Balochistan 9 districts (R-07) 6925 5987 86.5 4969 71.8 5927 85.6
6 districts (R-10) 3575 3407 95.3 2808 78.5 3168 88.6
7 districts 3856 3262 84.6 2812 72.9 2987 77.5
KPK 3 districts (R-07) 1875 1518 81.0 1290 68.8 1501 80.1
4 districts (R-10) 1981 1744 88.0 1522 76.8 1486 75.0
10 districts 3869 3676 95.0 3189 82.4 3107 80.3
FATA 3 districts (R-07) 1627 1578 97.0 1435 88.2 1456 89.5
7 districts (R-10) 2242 2098 93.6 1754 78.2 1651 73.6
38 districts 23739 21277 89.6 18838 79.4 20087 84.6
Total 19 districts (R-07) 14907 13084 87.8 11797 79.1 12852 86.2
19 districts (R-10) 8832 8193 92.8 7041 79.7 7235 81.9
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4.3. ATTITUDE AND PRACTICES FOR MALARIA PREVENTION
4.3.1. Treatment Seeking Behaviour
A total of 717 respondents had fever at the time of survey. When inquired as to when they sought treatment for this fever, 65% individuals reported that they took treatment within 24 hours of the onset of fever while, 34% got treatment within 48 hours. Only 1.1% waited for 72 hours before seeking some treatment (Table 18).
Table 18: Treatment seeking behavior in fever cases at the time of survey
Seek treatment
Province Fever Within 24 hours 48 hours 72 hours
Nos. % Nos. % Nos. %
Sindh 85 35 41.2 49 57.6 1 1.2
Balochistan 253 123 48.6 129 51.0 1 0.4
KPK 129 98 76.0 25 19.4 6 4.6
FATA 250 210 84.0 40 16.0 0 0.0
Total 717 466 65.0 243 33.9 8 1.1
The treatment seeking behavior of the community is shown in table 19. Respondents were asked how soon they generally seek treatment if they ever get fever. Almost 75% said that they usually take treatment during fever. Of these 64.8% reported seeking treatment within 24 hours, 28.1% within 48 hours and 7.1% within 72 hours. In Sindh majority (72%) of the respondents said they take treatment within 24 hours of the onset of fever but in other provinces this frequency was low and ranged between 57-60%. There was not much difference in the treatment seeking behavior of the patients suffering from fever at the time of survey and those who ever suffered from fever in the community, indicating that their attitudes and practices are almost similar.
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Table 19 : Treatment-seeking behavior in those who ever had fever (38 districts) Seek Following fever (hours) Fever House- treatment Province Districts hold Within 24 48 hrs 72 hrs Nos. % Nos. % Nos % Nos % Nos % 2047 431 21.1 387 89.8 279 72.1 85 22.0 23 5.9 Sindh 4 dist. (R-07) 1373 328 23.9 301 91.8 242 80.4 45 15.0 14 4.7
2 dist. (R-10) 674 103 15.3 86 83.5 37 43.0 40 46.5 9 10.5
Balochistan. 15 districts 3607 954 26.4 575 60.3 331 57.6 196 34.1 48 8.3 9 dist.(R-07) 2170 610 28.1 417 68.4 253 60.7 134 32.1 30 7.2
6 dist.(R-10) 1437 344 23.9 158 45.9 78 49.4 62 39.2 18 11.4
KPK 7 districts 2353 324 13.8 256 79 152 59.4 69 27.0 35 13.7 3 dist. (R-07) 1000 128 12.8 116 90.6 73 62.9 29 25.0 14 12.1
4 dist. (R-10) 1353 196 14.5 140 71.4 79 56.4 40 28.6 21 15.0
FATA 10 districts 2552 826 32.4 702 85 482 68.7 190 27.1 30 4.3 3 dist. (R-07) 890 247 27.8 184 74.5 103 56.0 64 34.8 17 9.2
7 dist.(R-10) 1662 579 34.8 518 89.5 379 73.2 126 24.3 13 2.5
Total 38 districts 10559 2535 24 1920 75.7 1244 64.8 540 28.1 136 7.1 19 dist.(R-07) 5433 1313 24.2 1018 77.5 671 65.9 272 26.7 75 7.4
19 dist.(R-10) 5126 1222 23.8 902 73.8 573 63.5 268 29.7 61 6.8
4.3.2. Self Treatment of malaria About 28% of the population self treated malaria (Table 20) using either allopathic (78.8%) or homeopathic (14.4%) medicines. Only 6.8% used home remedies. Within the provinces similar pattern was observed except in Balochistan where homeopathic treatment was taken least frequently (4.6%). The preference of using a health facility i.e. government vs. private for seeking treatment is shown in table 21. Overall 50.6% population took treatment from government health facility and 49.4% from other sources such as private clinics (37.5%), LHWs (9.8%), hakims, homeopaths, spiritual healers etc. Preference to use a government health facility was mostly seen in FATA (62.8%) and Balochistan (58.2%) followed by Sindh (38.2%) and KPK (37.7%). Reasons for not using government health facilities are shown in table 22. These included dissatisfaction with the services (44.3%), non availability of medicines (42.3%) or staff (17.1%), facility far away (16.3%), difficult access (10.9%) and staff behavior (12%). About 9.0% reported non-existent health facility in their area or UCs.
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Table 20: Self treatment of malaria
Self Home House- Allopathic Homeopathic Round treatment Remedies hold Nos. % Nos. % Nos. % Nos. %
6 districts 2047 521 25.5 364 69.9 76 14.6 81 15.5
Sindh 4 dist. (R-07) 1373 341 24.8 216 63.3 52 15.2 73 21.4
2 dist. (R-10) 674 180 26.7 148 82.2 24 13.3 8 4.4
15 districts 3607 606 16.8 467 77.1 28 4.6 111 18.3
Baloch -istan 9 dist. (R-07) 2170 444 20.5 348 78.4 24 5.4 72 16.2
6 dist. (R-10) 1437 162 11.3 119 73.5 4 2.5 39 24.1
7 districts 2353 761 32.3 596 78.3 156 20.5 9 1.2
KPK 3 dist. (R-07) 1000 337 33.7 184 54.6 150 44.5 3 0.9
4 dist. (R-10) 1353 424 31.3 412 97.2 6 1.4 6 1.4
10 districts 2552 1068 41.8 901 84.4 165 15.4 2 0.2
FATA 3 dist. (R-07) 890 523 58.8 515 98.5 7 1.3 1 0.2
7 dist. (R-10) 1662 545 32.8 386 70.8 158 29.0 1 0.2
38 districts 10559 2956 28.0 2328 78.8 425 14.4 203 6.8
Total 19 dist.(R-07) 5433 1645 30.3 1263 76.8 233 14.2 149 9.1
19 dist. (R-10) 5126 1311 25.6 1065 81.2 192 14.6 54 4.1
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Table 21: Preference for using public or private facility and the type of health care provider for treatment of fever
Preferred site for treatment of fever House Province District Pvt. Manage Home- Spirit. Med. Hold Govt. LHW Hakim Other Pract. at home opath Healer Store
6 district 2081 Nos. 795 1241 12 3 6 3 17 3 1 % 38.2 59.6 1.0 0.1 0.3 0.1 0.8 0.1 0.0
4 dist. (R-07) 1390 Nos. 474 882 2 3 6 3 16 3 1 Sindh % 34.1 63.5 0.2 0.2 0.4 0.2 1.2 0.2 0.1
2 dist. (R-10) 691 Nos. 321 359 10 0 0 0 1 0 0 % 46.5 52.0 2.8 0.0 0.0 0.0 0.1 0.0 0.0
15 districts 3728 Nos. 2170 1238 58 26 11 13 159 53 0 % 58.2 33.2 4.7 0.7 0.3 0.3 4.3 1.4 0.0
Baloch- 9 dist.(R-07) 2220 Nos. 1231 742 47 13 9 13 114 51 0 istan % 55.5 33.4 6.3 0.6 0.4 0.6 5.1 2.3 0.0
6 dist. (R-10) 1508 Nos. 939 496 11 13 2 0 45 2 0 % 62.3 32.9 2.2 0.9 0.1 0.0 3.0 0.1 0.0
7 districts 2500 Nos. 917 930 186 40 27 19 150 205 26 % 36.7 37.2 20.0 1.6 1.1 0.8 6.0 8.2 1.0
3 dist. (R-07) 1049 Nos. 232 601 141 2 4 2 46 19 2 KPK % 22.1 57.3 23.5 0.2 0.4 0.2 4.4 1.8 0.2
4 dist. (R-10) 1451 Nos. 685 329 45 38 23 17 104 186 24 % 47.2 22.7 13.7 2.6 1.6 1.2 7.2 12.8 1.7
10 districts 2595 Nos. 1630 685 146 0 3 2 54 43 32 % 62.8 26.4 21.3 0.0 0.1 0.1 2.1 1.7 1.2
3 dist. (R-07) 900 Nos. 702 60 83 0 1 0 14 21 19 FATA % 78.0 6.7 138.3 0.0 0.1 0.0 1.6 2.3 2.1
1695 Nos. 928 625 63 0 2 2 40 22 13 7 dist. (R-10) % 54.7 36.9 10.1 0.0 0.1 0.1 2.4 1.3 0.8
38 districts 10904 Nos. 5512 4094 402 69 47 37 380 304 59 Total % 50.6 37.5 9.8 0.6 0.4 0.3 3.5 2.8 0.5
5559 Nos. 2639 2285 273 18 20 18 190 94 22 19 dist. (R-07) % 47.5 41.1 11.9 0.3 0.4 0.3 3.4 1.7 0.4
19 dist.(R-10) 5345 Nos. 2873 1809 129 51 27 19 190 210 37 % 53.8 33.8 7.1 1.0 0.5 0.4 3.6 3.9 0.7
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Table 22: Reasons for not using government health facilities. Not Reasons for not using Govt. health facility using (number & percentage are cumulative) Province Districts Govt. Health Nos Far Difficult Dissat Staff Staff NA facility H.F away Access isfied NA Behav. Med. Other No. 143 106 104 569 104 210 503 8 6 districts 1286 % 11.1 8.2 8.1 44.2 8.1 16.3 39.1 0.6 Sindh No. 140 68 83 322 80 164 466 5 4 districts (R-07) 916
% 15.3 7.4 9.1 35.2 8.7 17.9 50.9 0.5 No. 3 38 21 247 24 46 37 3 2 districts (R-10) 370 % 0.8 10.3 5.7 66.8 6.5 12.4 10.0 0.8
15 districts 1558 No. 139 120 50 597 257 113 790 15 % 8.9 7.7 3.2 38.3 16.5 7.3 50.7 1.0 Balochistan No. 135 96 48 380 202 97 529 7 9 districts (R-07) 989 % 13.7 9.7 4.9 38.4 20.4 9.8 53.5 0.7 No. 4 24 2 217 55 16 261 8 6 districts (R-10) 569 % 0.7 4.2 0.4 38.1 9.7 2.8 45.9 1.4 No. 184 516 322 847 403 297 662 95 7 districts 1524 % 11.6 32.6 20.3 53.5 25.5 18.8 41.8 6.0 KPK No. 101 247 250 502 187 117 381 83 3 districts (R-07) 484 % 12.4 30.2 30.6 61.4 22.9 14.3 46.6 10.2 No. 83 269 72 345 216 180 281 12 4 districts (R-10) 766 % 10.8 35.1 9.4 45.0 28.2 23.5 36.7 1.6 No. 18 139 114 376 157 26 327 24 10 districts 965 % 1.9 14.4 11.8 39.0 16.3 2.7 33.9 2.5 FATA No. 12 29 20 49 4 4 3 10 3 districts (R-07) 198 % 6.1 14.6 10.1 24.7 2.0 2.0 1.5 5.1
7 districts (R-10) 767 No. 6 110 94 327 153 22 324 14 % 0.8 14.3 12.3 42.6 19.9 2.9 42.2 1.8 No. 484 881 590 2389 921 646 2282 142 38 districts 5392 % 9.0 16.3 10.9 44.3 17.1 12.0 42.3 2.6 Total No. 388 440 401 1253 473 382 1379 105 19 districts (R-07) 2920 % 13.3 15.1 13.7 42.9 16.2 13.1 47.2 3.6 No. 96 441 189 1136 448 264 903 37 19 districts (R-10) 2472 % 3.9 17.8 7.6 46.0 18.1 10.7 36.5 1.5
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Distance of the government health facility from the place of residence had a major impact on its use. The health facility was maximally used when it was closer to the residence and as the distance increased, its utilization decreased. Of those who used the government facility, majority (89%) mentioned its distance to be less than 5 Km, 39.1% said it was between 5-10 kilometers and 7% indicated more than 10 kilometers (Table 23).
Table 23: Distance of government health facilities from the place of residence of the surveyed households
Distance of health facility from home House- Province Districts Govt. % < 5 km 5-10 km > 10 km hold Nos. % Nos. % Nos. %
6 districts 2081 795 38.2 488 61.4 205 25.8 102 12.8
Sindh 4 dist.(R-07) 1390 474 34.1 251 53.0 131 27.6 92 19.4
2 dist.(R-10) 691 321 46.5 237 73.8 74 23.1 10 3.1
15 districts 3728 2170 58.2 1833 84.5 254 11.7 83 3.8
Balochistan 9 dist.(R-07) 2220 1231 55.5 1016 82.5 183 14.9 32 2.6
6 dist.(R-10) 1508 939 62.3 817 87.0 71 7.6 51 5.4
7 districts 2400 876 36.5 737 84.1 128 14.6 11 1.3 KPK 3 dist.(R-07) 649 165 25.4 123 74.5 38 23.0 4 2.4 4 dist.(R-10) 1451 685 47.2 568 82.9 105 15.3 12 1.8
10 districts 2595 1630 62.8 1386 85.0 160 9.8 84 5.2
FATA 3 dist.(R-07) 900 702 78 631 89.9 20 2.8 51 7.3
7 dist.(R-10) 1695 928 54.7 755 81.4 140 15.1 33 3.6
38 districts 10904 5512 50.6 4458 80.9 768 13.9 286 5.2
Total 19 dist.(R-07) 5159 2572 49.9 2021 78.6 372 14.5 179 7.0 19 dist.(R-10) 5345 2873 53.8 2377 82.7 390 13.6 106 3.7
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Table 24 shows the approximate transport cost incurred by the people to reach the health facility. Almost 50% reported spending between Rupees 100-500, whereas 37% spent less than Rupees 100. Highest cost incurred for round trip from home to hospital and back was seen in KPK and Balochistan where, due to scattered population, longer distances were travelled by the users to reach the health facility.
Table 24: Health facility access: round trip cost (Rupees) incurred by the households Transport (Round trip) cost in rupees Inform. Provinces Districts Govt. Available ≤100 100-500 501-1000 >1000 Nos. % Nos. % Nos. % Nos. %
6 districts 795 532 316 59.4 159 29.9 50 9.4 7 1.3
Sindh 4 districts (R-07) 474 349 187 53.6 117 33.5 39 11.2 6 1.7
2 districts (R-10) 321 183 129 70.5 42 23.0 11 6.0 1 0.5
15 districts 2170 1016 317 31.2 440 43.3 174 17.1 85 8.4
Balochistan 9 districts (R-07) 1231 658 302 45.9 269 40.9 58 8.8 29 4.4
6 districts (R-10) 939. 358 15 4.2 171 47.8 116 32.4 56 15.6
7 districts 1012 647 281 43.4 312 48.2 40 6.2 14 2.2
KPK 3 districts (R-07) 232 163 57 35.0 79 48.5 15 9.2 12 7.4
4 districts (R-10) 685 484 224 46.3 233 48.1 25 5.2 2 0.4
1630 787 186 23.6 576 73.2 24 3.0 1 0.1 10 districts
FATA 702 204 7 3.4 196 96.1 1 0.5 0 0.0 3 districts (R-07)
928 583 179 30.7 380 65.2 23 3.9 1 0.2 7 districts (R-10)
38 districts 5512 2982 1100 36.9 1487 49.9 288 9.7 107 3.6
Total 19 districts (R-07) 2639 1374 553 40.2 661 48.1 113 8.2 47 3.4
19 districts (R-10) 2873 1608 547 34.0 826 51.4 175 10.9 60 3.7
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Table 25 shows the time lapse between patients reaching the health facility and being examined by the health care provider. Once reached almost 2/3rd of the patients (77%) were seen within an hour while remaining 23% were seen in more than one hour. Almost similar responses were received from all provinces.
Table 25: Time taken to access the health care provider Time taken to see health care House- Provinces Districts Govt. provider Hold <1 hour % >1 hour %
6 districts 2081 795 562 70.7 233 29.3
Sindh 4 districts (R-07) 1390 474 307 64.8 167 35.2
2 districts (R-10) 691 321 255 79.4 66 20.6
15 districts 3728 2170 1498 69.0 672 31.0
9 districts (R-07) 2220 1231 839 68.2 392 31.8 Balochistan 6 districts (R-10) 1508 939. 659 70.2 280 29.8
7 districts 2750 1012 835 82.5 177 17.5
3 districts (R-07) 1049 232 189 81.5 43 18.5 KPK
4 districts (R-10) 1451 685 565 82.5 120 17.5
10 districts 2595 1630 1449 88.9 181 11.1
FATA 3 districts (R-07) 900 702 655 93.3 47 6.7
7 districts (R-10) 1695 928 794 85.6 134 14.4
38 districts 10904 5512 4263 77.3 1249 22.7
Total 19 districts (R-07) 5559 2639 1990 75.4 649 24.6
19 districts (R-10) 5345 2873 2273 79.1 600 20.9
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5. COVERAGE OF MALARIA PRVENTION INTERVENTIONS
Malaria control efforts in Pakistan are focused around some selected interventions for rapid scale up. These include providing prompt and effective treatment within 24 hours of the onset of symptoms, prevention of malaria transmission by using long lasting insecticide-treated mosquito nets (LLINs) and use of indoor residual spraying (IRS) in high malaria transmission areas.
This chapter presents findings on the household coverage by IRS and LLINs. The findings also include characteristics and usage of nets, people (especially the children below 5 years and pregnant women) who slept under LLINs the night before the survey.
5.1. INDOOR RESIDUAL SPRAYING Households were inquired if their house was sprayed at any time during the last 12 months and if yes by whom. Table 26 shows that out of 10,588 households surveyed, 11% reported that their house was sprayed in the past 12 months. The spray was mostly done by the government (62.6%) followed by the private sector (34%). Maximum households were sprayed in FATA (17.3%) and minimum in Balochistan (7.1%).
In Sindh maximum households were sprayed in district Tando Allah Yar (29.3%, n=86) and minimum in Tharparkar/Mithi (1.2%, n= 3). In Balochistan maximum households were sprayed in districts Zhob/Sherani (26.5% n= 66) followed by Washuk (21.3%, n=40), Gawadar (16.5%, n=41) and Noushki (12%, n=24). In many districts in Balochistan the proportion of houses sprayed ranged between 0.4 – 6.4%. In Khyber Pukhutoon Khwa (KPK) maximum houses were sprayed in district Lakki Marwat (19%, n=56) followed by Tank (15.7%, n=47) while, in other districts it ranged between 1.0 – 9.4%. In FATA region maximum households were sprayed in North Waziristan (43%, n-106), followed by Kurrum Agency (39%, n=117), South Waziristan (20.3%, n-61), FR Peshawar/Kohat (19.7%, n=49) and Bajaur Agency (16.3%, n=49) and Khyber Agency (14.3%, n=43). In the remaining four districts the proportion of house sprayed ranged between 0.5 – 5%.
When compared between Round-7 and Round-10 districts almost similar numbers of households were sprayed during the last 12 months.
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Table 26: Households sprayed using IRS in the last 12 months in 38 districts
Sprayed Sprayed by whom Province Districts House-hold Nos. % Govt. % Pvt. % D.K %
6 districts 2081 278 13.4 253 91.0 10 3.6 15 5.4
Sindh 4 districts (R-07) 1390 132 9.5 124 93.9 4 3.0 4 3.0
2 districts (R-10) 691 146 21.1 129 88.4 6 4.1 11 7.5
15 districts 3728 263 7.1 115 43.7 141 53.6 7 2.7
Balochistan 9 districts (R-07) 2220 175 7.9 106 60.6 66 37.7 3 1.7
6 districts (R-10) 1508 88 5.8 9 10.2 75 85.2 4 4.5
7 districts 2500 195 7.8 114 58.5 75 38.5 6 3.1
KPK 3 districts (R-07) 1049 83 7.9 57 68.7 22 26.5 4 4.8
4 districts (R-10) 1451 112 7.7 57 50.9 53 47.3 2 1.8
10 districts 2595 448 17.3 259 57.8 176 39.3 13 2.9
FATA 3 districts (R-07) 900 209 23.2 175 83.7 30 14.4 4 1.9
7 districts (R-10) 1695 239 14.1 84 35.1 146 61.1 9 3.8
38 districts 10904 1184 10.9 741 62.6 402 34.0 41 3.5
Total 19 districts (R-07) 5559 599 10.8 462 77.1 122 20.4 15 2.5
19 districts (R-10) 5345 585 10.9 279 47.7 280 47.9 26 4.4
5.2. LONG LASTING INSECTICIDE TREATED NETS (LLINS) The households were asked whether they owned any mosquito nets and if so, how many (1, 2 or more than 2 nets) and since when do they have these nets. For the purpose of this survey, a long-lasting insecticidal net (LLIN) was defined as a “factory-manufactured net that does not require any treatment”. The untreated net was defined as the net traditionally used by the population. Net usage was defined as “any person who slept under a particular net the night prior to the survey”. Respondents were asked to show their nets to the interviewer to verify their presence.
5.2.1. Ownership, acquisition & source of long lasting iinsecticide treated nets Table 27 shows the percentage of households that had at least one mosquito net and its source of acquisition. Overall 34% households had at least one LLIN and out of these 80% nets were
46 personally observed by the survey team members. Province wise, maximum households in FATA had at least one net (56%) followed by Balochistan (37.7%), Sindh (22.1%) and KPK (15%). Maximum proportion of households (77.5%) acquired LLINs in the last one year. Table 27: Households having at least one LLIN or any other mosquito net (traditional untreated nets) (38 districts)
House LLINs Observed LLINs Other Nets Province District hold Nos. % Nos. % Nos. % 6 districts 2081 459 22.1 371 80.8 533 25.6 Sindh 4 districts (R-07) 1390 216 15.5 172 79.6 134 9.6 2 districts (R-10) 691 243 35.2 199 81.9 399 57.7 15 districts 3728 1407 37.7 1219 86.6 1219 32.7 Balochistan 9 districts (R-07) 2220 819 36.9 759 92.7 564 25.4 6 districts (R-10) 1508 588 39.0 460 78.2 655 43.4 7 districts 2500 376 15.0 165 43.9 145 5.8 KPK 3 districts (R-07) 1049 152 14.5 67 44.1 30 2.9 4 districts (R-10) 1451 224 15.4 98 43.8 115 7.9 10 districts 2595 1452 56.0 969 66.7 463 17.8 FATA 3 districts (R-07) 900 638 70.9 452 70.8 182 20.2 7 districts (R-10) 1695 814 48.0 517 63.5 281 16.6 38 districts 10904 3694 33.9 2724 73.7 2360 21.6 Total 19 districts (R-07) 5559 1825 32.8 1450 79.5 910 16.4 19 districts (R-10) 5345 1869 35.0 1274 68.2 1450 27.1
Regarding source of acquiring LLINs, about 50.4% households reported that they got the LLIN from the government while, 37.5% got them from Non- government Organizations. About 9.0% of the households purchased these nets from the market (Table 28). Almost 21% households had mosquito nets other than LLINs and these were maximally seen in Balochistan (32%) indicating cultural acceptability of these mosquito nets.
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Table 28: Time and source of acquisition of nets
When received Who gave these nets Province District LLINs <1 yr 1-3 yrs DK Govt. NGO Self DK Nos. 338 95 26 354 36 55 14 6 districts 459 % 73.6 20.7 5.7 77.1 7.8 12.0 3.1 Nos. 137 58 21 149 13 44 10.0 Sindh 4 districts (R-07) 216 % 63.4 26.9 9.7 69.0 6.0 20.4 4.6 Nos. 201 37 5 205 23 11 4.0 2 districts (R-10) 243 % 82.7 15.2 2.1 84.4 9.5 4.5 1.6
Nos. 1137 168 102 676 659 44 28 15 districts 1407 % 80.8 11.9 7.2 48.0 46.8 3.1 2.0 Nos. 604 139 76 481 274 44 20 Balochistan 9 districts (R-07) 819 % 73.7 17.0 9.3 58.7 33.5 5.4 2.4 Nos. 533 29 26 195 385 0 8 6 districts (R-10) 588 % 90.6 4.9 4.4 33.2 65.5 0.0 1.4
Nos. 246 93 37 170 124 66 16 7 districts 376 % 65.4 24.7 9.8 45.2 33.0 17.6 4.3 Nos. 98 42 12 85 33 25 9 KPK 3 districts (R-07) 152 % 64.5 27.6 7.9 55.9 21.7 16.4 5.9 Nos. 148 51 25 85 91 41 7 4 districts (R-10) 224 % 66.1 22.8 11.2 37.9 40.6 18.3 3.1
Nos. 1143 223 86 662 568 169 53 10 districts 1452 % 78.7 15.4 5.9 45.6 39.1 11.6 3.7 Nos. 521 83 34 279 306 10 43 FATA 3 districts (R-07) 638 % 81.7 13.0 5.3 43.7 48.0 1.6 6.7 Nos. 622 140 52 383 262 159 10 7 districts (R-10) 814 % 76.4 17.2 6.4 47.1 32.2 19.5 1.2
Nos. 2864 579 251 1862 1387 334 111 38 districts 3694 % 77.5 15.7 6.8 50.4 37.5 9.0 3.0 Nos. 1360 322 143 994 626 123 82 Total 19 districts (R-07) 1825 % 74.5 17.6 7.8 54.5 34.3 6.7 4.5 Nos. 1504 257 108 868 761 211 29 19 districts (R-10) 1869 % 80.5 13.8 5.8 46.4 40.7 11.3 1.6
5.2.2. Coverage of LLINs in GF Covered and non Covered Union Councils. Table 29 shows comparison of LLIN coverage in the Union Councils of Round -7 districts which were covered by Global Fund support and those that were not covered by support. Overall coverage of nets was better in supported UCs. There were 1397 UCs covered through GF
48 support and out of these 15.8% houses had at least one LLIN as compared to 12% in the uncovered UCs. Likewise 17.7% and 6.3% households in the GF covered UCs had two or more than two nets respectively as compared to 9% and 2% households in the uncovered UCs.
Table 29: Distribution of LLINs in Union Councils covered or not covered with Global Fund support in 19 districts of Round-7 None One LLIN Two LLIN > two LLIN Total GF Covered/ House- Province not covered Hold % Nos % Nos % Nos % Nos Nos % Covered 299 231 77.3 50 16.7 15 5.0 3 1.0 68 22.7
Sindh Not covered 650 595 91.5 35 5.4 16 2.5 4 0.6 55 8.46
Covered 648 361 55.7 103 15.9 135 20.8 49 7.6 287 44.3
Balochistan Not covered 1031 813 78.9 75 7.3 109 10.6 34 3.3 218 21.1
Covered 200 176 88.0 15 7.5 4 2.0 5 2.5 24 12.0
KPK Not covered 100 87 87.0 11 11.0 1 1.0 1 1.0 13 13.0
Covered 250 73 29.2 53 21.2 93 37.2 31 12.4 177 70.8
FATA Not covered 350 131 37.4 135 38.6 65 18.6 19 5.4 219 66.6
Covered 1397 841 60.2 221 15.8 247 17.7 88 6.3 556 39.8
Total Not covered 2131 1626 76.3 256 12.0 191 9.0 58 2.7 505 23.7
Province wise coverage of nets is depicted in Figure 5. Overall 40% households had at least one LLIN in the GF supported UCs as compared to 23.7% households in the non-GF supported UCs. Except for KPK where, there was no difference in proportion of households in GF covered or uncovered districts all other provinces showed higher coverage in the Union Councils supported by GF. In Balochistan province almost double the households in the GF supported UCs had at least one LLIN as compared to non GF covered UCs.
District wise LLINs coverage for round-7 is shown in figure 6. Maximum coverage was seen in 2 districts i.e. Khyber (92%) and Kurrum (80%).
Figure 7 shows coverage of UCs in round-10 districts. Of the 19 districts, maximum coverage was seen in 3 districts i.e. Chagi (79%), South Waziristan (78.3%) and North Waziristan (67.6%).
49
Figure 5: Province wise distribution of LLINs in union councils covered and not covered with Global Fund support in Round-7
50
Figure 6: District wise coverage of LLINs in 19 districts of R-7
Figure 7: District wise coverage of LLINs in 19 districts of R-10
51
5.2.3. Usage of Mosquito Nets Around 34.8% family members of all ages reported sleeping under LLIN in the previous night (Table 30). Highest proportion of family members sleeping under LLINs was reported from Balochistan (58.1%) followed by Sindh (32.6%), FATA (23.6%) and KPK (15.9%). When compared between Round-7 and Round 10 districts, overall 42% family members in round 10 districts slept under LLINs the previous night of survey as compared to 29.2% in Round-7 districts.
Table 30: Percentage of all persons who slept under LLINs the night preceding the survey
Household Slept under LLIN Province District Household with LLIN Individuals Nos. %
6 districts 2081 459 2853 930 32.6
Sindh 4 districts (R-07) 1390 216 1292 419 32.4
2 districts (R-10) 691 243 1561 511 32.7
15 districts 3728 1407 7707 4479 58.1
Balochistan 9 districts (R-07) 2220 819 5163 2386 46.2
6 districts (R-10) 1508 588 2544 2093 82.3
7 districts 2500 376 3022 480 15.9
KPK 3 districts (R-07) 1049 152 1458 131 9.0
4 districts (R-10) 1451 224 1564 349 22.3
10 districts 2595 1452 10446 2469 23.6
FATA 3 districts (R-07) 900 638 5669 1033 18.2
7 districts (R-10) 1695 814 4777 1436 30.1
38 districts 10904 3694 24028 8358 34.8
Total 19 districts (R-07) 5559 1825 13582 3969 29.2
19 districts (R-10) 5345 1869 10446 4389 42.0
5.2.3.1. Net Usage by Children below 5 years of age
There were 8852 children under age 5 in the survey and out of these 21% slept under a mosquito net the previous night (Table 31). Maximum children sleeping under the LLIN was reported from Balochistan (35%) and lowest (3.8%) from KPK. When compared between
52 round-7 and 10 districts, a higher proportion of children below 5 years were sleeping under LLIN in Round-7 districts (24%) as compared to Round-10 districts (18%).
Table 31: Province wise percentage of children under five years who slept under LLIN the night preceding the survey.
Under 5 years House Household Province Districts hold with LLIN No. Slept LLIN %
6 districts 2081 459 1606 194 12.1
Sindh 4 districts (R-07) 1390 216 1089 140 12.9
2 districts (R-10) 691 243 517 54 10.4
15 districts 3728 1407 2961 1037 35.0
Balochistan 9 districts (R-07) 2220 819 1889 596 31.6
6 districts (R-10) 1508 588 1072 441 41.1
7 districts 2500 376 2181 83 3.8
KPK 3 districts (R-07) 1049 152 952 22 2.3
4 districts (R-10) 1451 224 1229 61 5.0
10 districts 2595 1452 2104 563 26.8
FATA 3 districts (R-07) 900 638 764 371 48.6
7 districts (R-10) 1695 814 1340 192 14.3
38 districts 10904 3694 8852 1877 21.2
Total 19 districts (R-07) 5559 1825 4694 1129 24.1
19 districts (R-10) 5345 1869 4158 748 18.0
53
5.2.3.2. Net Usage by Pregnant women
Overall, there were 290 pregnant women in the survey. Of these 28% slept under LLIN the previous night. This percentage was highest in FATA (52.3%) followed by Balochistan (31.4%) (Table 32)
Table 32: Province wise percentage of pregnant women who slept under LLIN the night preceding the survey
Household Pregnant women Province Districts Household with LLIN No. Slept LLIN % 6 districts 2081 459 185 22 11.9
4 districts (R-07) Sindh 1390 216 134 10 7.5
2 districts (R-10) 691 243 51 12 23.5
15 districts 3728 1407 586 184 31.4
9 districts (R-07) Balochistan 2220 819 435 132 30.3
6 districts (R-10) 1508 588 151 52 34.4
7 districts 2500 376 121 15 12.4
3 districts (R-07) KPK 1049 152 40 1 2.5
4 districts (R-10) 1451 224 81 14 17.3
10 districts 2595 1452 132 69 52.3
3 districts (R-07) FATA 900 638 74 56 75.7
7 districts (R-10) 1695 814 58 13 22.4
38 districts 10904 3694 1024 290 28.3
19 districts (R-07) Total 5559 1825 683 199 29.1
19 districts (R-10) 5345 1869 341 91 26.7
54
6. PARASITE PREVALENCE
This chapter presents the prevalence of malaria parasites in 19 districts of GF Round-10 by district and province. It includes information on the number of cases suffering from fever at the time of survey, malaria microscopy, RDT results, Plasmodium falciparum to Plasmodium vivax ratio, and slide positivity rate in the sampled population.
Parasite prevalence, which is measured through periodic community surveys, provides a measure of the percent of general population that is infected with malaria parasites, regardless of symptoms. Microscopy is the gold standard for measuring parasite prevalence.
6.1. ELIGIBLE PERSONS TESTED FOR MALARIA
Malaria microscopy was carried out in all individuals living in a household. Out of 31,317 eligible individuals, 22,415 were tested for malaria parasites by microscopy as 18% refused testing and 10.5% were absent from their households at the time of survey. Maximum absenteeism and refusals were observed in Balochistan (5.5 and 29.3% respectively) and FATA (14.2 and 14.7% respectively) (Table 33).
Table 33: Persons tested for malaria using microscopy in 19 Districts of Round 10
Nos. of Tested Absent Refusal Province Districts subject Tested % Absent % Refusal %
Sindh 2 districts 3598 2749 76.4 268 7.4 581 16.1
Balochistan 6 districts 7836 5110 65.2 430 5.5 2296 29.3
KPK 4 districts 10137 7624 75.2 1219 12.0 1294 12.8
FATA 7 districts 9746 6932 71.1 1382 14.2 1432 14.7
Total 19 districts 31317 22415 71.6 3299 10.5 5603 17.9
55
6.2. PREVALENCE OF MALARIA PARASITES
Table 34 shows the prevalence of malaria in 19 districts of R-10, its rate per 1000 population and Plasmodium vivax (PV) to Plasmodium falciparum (PF) ratio. Overall malaria prevalence in these districts was 1.59% (15.9/1000 population). The prevalence was highest in FATA (27.5/1000 population) followed by KPK (12.5/1000 population), Balochistan (11.3/1000 population) and Sindh (1.8/1000 population). Overall the PV:PF ratio was 84:16. Highest falciparum prevalence was found in FATA (4.5/1000 population) followed by Balochistan (4.0/1000 population).
Table 34: Province wise prevalence of malaria (Microscopy+ RDTs) and PV: PF ratio
Cases Vivax Falciparum Province Tested Positive % Per Per Per 1000 Nos % Nos. % PV : PF 1000 1000
Sindh 2749 5 0.18 1.8 4 0.15 1.5 1 0.04 0.4 80 : 20
Balochistan 5316 60 1.13 11.3 37 0.70 7.0 21 0.40 4.0 64 : 36
KPK 6853 86 1.25 12.5 84 1.23 12.3 2 0.03 0.3 98 : 02
FATA 7497 206 2.75 27.5 171 2.28 22.8 34 0.45 4.5 83 : 17
Total 22415 357 1.59 15.9 296 1.32 13.2 58 0.26 2.6 84 : 16
(Mixed = 3 not included)
Table 35 shows prevalence of malaria by gender, age and marital status. Overall there was no difference in the prevalence among males (16.3/1000 population) and females (15.6/1000 population). Maximum prevalence was seen in children between 5-14 years (18.1/1000 population) followed by under five years of age (16.1/1000 population). The prevalence was almost similar in the population who was between 15-49 years (14.6/1000 population) and those who were 50 years or above (14.2/1000 population). Province wise distribution of parasite prevalence by age is annexed in the appendix-A. The prevalence was higher in un- married (18.6/1000) as compared to married (14.0/1000) population. The prevalence among currently pregnant women was 8.4/1000 population.
56
Table 35: Prevalence of malaria by gender, age and marital status (microscopy + RDTs)
Prevalence of Malaria
Variables Tested Nos. positive Percent Per 1000
Gender (n=22415)
11734 Male 190 1.63 16.3
10681 Female 167 1.56 15.6
Age in years (22399)
Under 5 3212 52 1.63 16.2
5-14 7219 131 1.81 18.1
15-49 10204 149 1.46 14.6
50 & above 1764 25 1.42 14.2
Marital Status (n=20785)
Married 8707 122 1.40 14.0
Un married 12078 225 1.86 18.6
Currently Pregnant 228 2 0.84 8.4 women
57
6.3. SLIDE POSITIVITY RATE Table 36 shows slide positivity rate (SPR) in each district irrespective of whether these cases had fever or not at the time of testing. Overall slide positivity rate was 1.41% (5.6% in fever cases and 1.3% in non fever cases). An unusually higher SPR was seen North Waziristan (7.84%).
Table 36: Slide positivity rate of malaria in 19 districts of Round-10 Total Total With Positive on Without Positive on Slides slides % Fever Microscopy Fever Microscopy (Fever + positive Positive Non fever)
Individ- District Nos. % Individuals Nos. % Nos. Nos. uals Tando Allah Yar 40 0 0 1186 1 0.1 1226 1 0.08 Mirpurkhas 45 0 0 1478 3 0.2 1523 3 0.20 Panjgur 67 0 0 518 0 0 585 0 0.00 Kharan 14 0 0 1044 1 0.1 1058 1 0.09 Chagi 37 8 21.6 981 0 0 1018 8 0.79 Washuk 24 0 0 658 8 1.2 682 8 1.17 Pishin 20 0 0 1201 1 0.1 1221 1 0.08 Musakhel 91 9 9.9 661 27 4.1 752 36 4.79 Tank 29 4 13.8 1602 29 1.8 1631 33 2.02 Charsada 22 0 0 2018 18 0.9 2040 18 0.88 Nowshera 10 0 0 1534 17 1.1 1544 17 1.10 D.I.Khan 68 0 0 1570 13 0.8 1638 13 0.79 North 39 3 7.7 994 78 7.8 1033 81 7.84 Waziristan Orakzai 33 3 9.1 766 2 0.3 799 5 0.63 Mohmand 77 2 2.6 1599 27 1.7 1676 29 1.73 South 6 0 0 1255 12 1 1261 12 0.95 Waziristan FR Peshawar / 34 1 2.9 1171 6 0.5 1205 7 0.58 Kohat FR Bannu / 44 3 6.8 647 14 2.2 691 17 2.46 Lakki FR Tank / DI 17 7 41.2 815 20 2.5 832 27 3.25 Khan Total 717 40 5.6 21698 277 1.3 22415 317 1.41
58
6.4. PREVALENCE OF FEVER AT THE TIME OF SURVEY A total of 717 (2.3%) persons had fever at the time of survey with slightly more females (2.5%) as compared to males (2.1%). The lowest percentage of fever was reported from KPK (1.3%). In other provinces the frequency of fever ranged between 1.3-3.1%. (Table 37)
Table 37: Prevalence of fever at the time of survey in Round-10
House Individuals Male Female Province Hold Nos. Fever % Nos. Fever % Nos. Fever %
Sindh 691 3599 90 2.5 1889 47 2.5 1710 43 2.5
Balochistan 1508 8130 255 3.1 4333 122 2.8 3797 133 3.5
KPK 1451 9272 124 1.3 4620 62 1.3 4652 62 1.3
FATA 1695 10317 248 2.4 6066 121 2.0 4251 127 3.0
Total 5345 31318 717 2.3 16908 352 2.1 14410 365 2.5
Table 38 shows age wise percentage of fever cases. About 3.6% were children below 5 years of age, 2.5% were between 5-14 years and 1.9% were 15 years and above. The percentage of children presenting with fever was highest in Sindh (7.2%), followed by Balochistan (4.7%), FATA (3.4%) and KPK (1.4%). Table 38: Age wise prevalence of fever at the time of survey in Global Fund Round-10 districts Under 5 years 5 – 14 years 15 years & above Province No. Fever % No. Fever % No. Fever % Sindh 517 37 7.2 1081 33 3.1 1997 20 1.0
Balochistan 1072 50 4.7 2434 73 3.0 4600 131 2.8
KPK 1229 17 1.4 2609 33 1.3 5417 74 1.4
FATA 1340 46 3.4 3216 92 2.9 5756 111 1.9
Total 4158 150 3.6 9340 231 2.5 17770 336 1.9
59
RDT were performed only in individuals who had fever at the time of survey. Overall 72 (10%) fever cases were positive on RDTs. Out of these 46 (63%) were positive for Plasmodium vivax and 17 (24%) Plasmodium falciparum. Nine fever cases (13%) had mixed infection (Table 39).
6.5. FEVER CASES POSITIVE ON RDTs
Table 39: Results of RDT in fever cases in 19 districts of Round-10 RDT done House- Indivi RDT Positive Type of malaria Province in Fever holds duals cases Nos. % PV PF Mixed Sindh 691 3599 85 2 2.4 1 1 0
Balochistan 1508 8130 253 20 7.9 14 3 3
KPK 1451 9272 129 8 6.2 7 1 0
FATA 1695 10317 250 42 16.8 24 12 6
Total 5345 31318 717 72 10.0 46 (63%) 17 (24%) 9 (13%)
6.6. FEVER CASES POSITIVE ON MICROSCOPY Table 40 shows that out of 717 cases who had fever, 5.6% were also positive on microscopy. About 1.3% cases were positive on microscopy, though they had no fever when interviewed.
Table 40: Proportion of fever and non fever cases positive on microscopy
Positive on Positive on With Fever Without Microscopy Microscopy fever
Province Individuals (%) Nos. % Individuals Nos. %
Sindh 85 (4) 0 0.0 2664 4 0.2
Balochistan 253 (54) 17 6.7 5063 37 0.7
KPK 129 (81) 4 3.1 6724 77 1.1
FATA 250 (178) 19 7.6 7247 159 2.2
Total 717 (317) 40 5.6 21698 277 1.3
6.7. MORTALITY DUE TO MALARIA (VERBAL AUTOPSY) The heads of the surveyed households in 38 districts were asked to recall if any death had occurred in their family during the last 10 years due to malaria (table 41). Over all 42 deaths were recalled by the head of households. Out of these 20 deaths were recalled in males and 60
22 females. Eighteen (18) were children below 5 years of age (42.9%), 9 were between 5-14 (21.4%) years of age and 15 were ≥15 years of age (36.7%). Maximum number deaths (20 persons) were reported from Sindh province followed by KPK (13 persons). Relationship of the deceased with the head of the household is shown in table 42. Overall 36% who died because of malaria were sons and 31% daughters.
Table 41: Mortality in the last 10 years by gender and age Gender Age in years Province District Mortality Male Female Under 5 5-14 ≥15 10 10 11 2 7 3 districts 20 Sindh 50.0 50.0 55.0 10.0 35.0
10 10 11 2 7 Round-7 (3 districts) 20 50.0 50.0 55.0 10.0 35.0 Round-10 (0 districts) ------
4 2 2 2 2 6 districts 6 Balochistan 66.7 33.3 33.3 33.3 33.3
3 1 2 - 2 Round-7 (4 districts) 4 75.0 25.0 50.0 - 50.0 1 1 - 2 0 Round-10 (2 districts) 2 50.0 50.0 - 100.0 0.0
5 districts 4 9 3 4 6 13 KPK 30.8 69.2 23.1 30.8 46.2
Round-7 (2 districts) 1 3 - 1 3 4
25.0 75.0 - 25.0 75.0 Round-10 (3 districts) 3 6 3 3 3 9 33.3 66.7 33.3 33.3 33.3
2 districts 2 1 2 1 - 3 FATA 66.7 33.3 66.7 33.3 -
Round-7 (1 districts) - 1 1 - - 1
- 100.0 100.0 - - Round-10 (1 districts) 2 - 1 1 - 2 100.0 - 50.0 50.0 -
16 districts 20 22 18 9 15 42 Total 47.6 52.4 42.9 21.4 35.7
Round-7 (10 districts) 14 15 14 3 12 29
48.3 51.7 48.3 10.3 41.4 Round-10 (06 districts) 6 7 4 6 3 13 46.2 53.8 30.8 46.2 23.1
61
Table 42: Relationship of the deceased with Head of Household
Relationship with Head of Household
Province District Mortality
Father Mother Sister Brother Son Daughter Other
3 districts - 1 - - 10 7 2 20 - 5.0 - - 50.0 35.0 10.0 Round-7 - 1 - - 10 7 2 Sindh (3 districts) 20 - 5.0 - - 50.0 35.0 10.0 Round-10 ------(0 districts) ------
2 - - - 2 2 6 districts 6 33.3 - - - 33.3 33.3 Round-7 2 - - - 1 1 Balochistan 4 (4 districts) 50.0 - - - 25.0 25.0 Round-10 - - - - 1 1 2 (2 districts) - - - - 50.0 50.0
1 1 2 1 1 3 4 5 districts 13 7.7 7.7 15.4 7.7 7.7 23.1 30.8 Round-7 1 1 1 1 KPK 4 (2 districts) 25.0 25.0 25.0 25.0 Round-10 - 1 1 1 1 2 3 9 (3 districts) - 11.1 11.1 11.1 11.1 22.2 33.3
- - - - 2 1 - 2 districts 3 - - - - 66.7 33.3 - Round-7 - - - - - 1 - FATA 1 (1 districts) - - - - - 100.0 - Round-10 - - - - 2 - - 2 (1 districts) - - - - 100.0 - -
3 2 2 1 15 13 6 16 districts 42 7.1 4.8 4.8 2.4 35.7 31.0 14.3
Round-7 3 1 1 0 11 10 3 Total 29 (10 districts) 10.3 3.4 3.4 0.0 37.9 34.5 10.3
Round-10 - 1 1 1 4 3 3 13 (06 districts) - 7.7 7.7 7.7 30.8 23.1 23.1
62
7. HOT SPOTS/HIGH RISK UCS
Out of 111 Union Councils surveyed, 13 (12%) showed a slide positivity rate of less than 1%, 26 (23%) had slide positivity rate ranging between 1-5% and 10 (9%) UCs had the slide positivity rate of more than 5% (hot spot). In the remaining 62 (56%) Union Councils the slide positivity rate was zero (Table 43). Slide positivity rate in individual union councils is annexed in appendix-A.
Table 43: Slide Positivity Rate by Union Councils
SPR 0 SPR >5 No. No. SPR 1-5 Province (malaria cases SPR < 1 (Epidemic District UCs (Control) not detected) Prone)
Sindh 02 14 11 (79%) 2 (14%) 1 (7%) 0
Balochistan 06 32 23 (72%) 2 (6%) 5 (16%) 2 (6%)
KPK 04 30 15 (50%) 5 (17%) 7 (23%) 3 (10%)
FATA 07 35 13 (37%) 4 (12%) 13 (37%) 5 (14%)
TOTAL 19 111 62 (56%) 13 (12%) 26 (23%) 10(9%)
Maps of 19 districts of Global Fund Round 10 showing slide positivity rate in each district along with hot spots of malaria is shown in figures 8-25.
63
Legends:
SPR > 5
SPR: 1- 5
SPR < 1
SPR = 0
Uncovered UCs
District Tank from Khyber Pakhtunkhwa with Union Councils
Figure 8: Union councils: Gul Imam, Dabarah, Tank Urban, Ranwal, Shah Alam and Sheikh Uttar
64
District Charsada from Khyber Pakhtunkhwa with Union Councils
Figure 9: Union councils: Agra, Behlola, Dakki, Daulatpura, Haji Zai, Hisara Nehri, Maira Prang and Shabqadar.
District Nowshera from Khyber Pakhtunkhwa with Union Councils
Figure 10: Union councils: Aman Kot, Dag Behsud, Jehangira, Kaka Sahib, Khairabad, Manki Sharif, Nawan Kali and Pir piai.
65
District D.I.Khan from Khyber Pakhtunkhwa with Union Councils
Figure 11: Union councils: Gara Isa Khan, Giloti, Kath Garh, Lar, Mohra and Zindani
District Tando Allah Yar from Sindh with Union Councils
Figure 12: Union councils: Bukera Shrif, Chamber, Desori, Missan and Sheikh Moosa
66
District Mirpurkhas from Sindh with Union Councils
Figure 13: Union councils: Kangoro, Khan, Khudad, Makhan Samoo, Meerwah, Nankot and soffan shah
District Panjgur from Baluchistan with Union Councils
Figure 14: Union councils: Bonistan, Chitkan, Gram Kan, Kallag, Sordo and Tasp
67
District Kharan from Baluchistan with Union Councils
Figure 15: Union Councils: Jamak, Janobicit, Moorvali, Raaskoh, Sarawan and TohMalak
District Chagi from Baluchistan with Union Councils
Figure 16: Union councils: Amin Abad, Amri, Nokhundi, Padag and Z. Balanosh
68
District Pishin from Baluchistan with Union Councils
Figure 17: Union councils: Ali Zai, B.Barshor, Barshor, Khano Zai Kariz, Manzari and ShakarZai
District Musakhel from Baluchistan with Union Councils
Figure 18: Union councils: Durak, Guryasa, Kangri, Musa Khawa and Saddar Bazar 69
Mohmand Agency from FATA Region
Figure 19: Mohamand Agency with Tehsils
Orakzai Agency from FATA Region
Figure 20: Orakzai Agency with Tehsils
70
North Waziristan Agency from FATA Region
Figure 21: North Waziristan Agency with Tehsils
South Waziristan Agency from FATA Region
Figure 22: South Waziristan Agency with Tehsils
71
FR Peshawar and FR Kohat from FATA Region
Figure 23: FR Peshawar Agency
FR DI Khan from FATA Region
Figure 24: FR D.I. Khan Agency
72
FR Bannu, FR Lakki Marwat and FR Tank from FATA Region
Figure 25: FR Bannu, FR Lakki Marwat and FR Tank Agencies
73
8.
74
8. HEALTH FACILITY SURVEY
The health facility survey included data on services provided, number of staff working for malaria and trainings that they received in 38 districts supported through GF-7 &10. Data was also collected on case management practices and malaria cases reported in 2012 and 2013.
A total of 198 health facilities (106 BHUs, 35 RHCs, 17 THQs ,31 DHQs and 09 others) were surveyed to collect data on various programmatic indicators. Out of the total, 103 (52%) health facilities were surveyed in 19 districts of GF Round-7 and 95 (48%) health facilities in 19 districts of GF Round-10 (Table 44).
Table 44: Categories of health facilities surveyed in GF 7 and 10 districts
Health facilities by Category
BHU RHC THQ DHQ Other Total Health Facilities Surveyed 55 20 8 17 3 103 (Round-07)
Health Facilities Surveyed 51 15 9 14 6 95 (Round-10)
TOTAL 106 35 17 31 9 198
8.1. STAFF WORKING FOR MALARIA IN HEALTH FACILITIES (2012 & 2013)
The staff working for malaria in the health facilities included medical officer (MO) and malaria staff; which in turn included all or any one of the three categories i.e. Lab Technician, Microscopist and CDC supervisor who were involved in diagnosis of malaria parasites.
In 2013, overall 80.2% of BHUs, 63% RHCs, 82.4% THQs and 64.5% DHQs had a Medical Officer involved in the treatment of malaria cases. Similarly the malaria related staff involved in malaria diagnosis were 83.5% at BHUs followed by 83% in RHCs, 94% in THQs and 96.8% in DHQs.
Comparison within the provinces showed that the health facilities in Balochistan had the lowest strength of medical officers and staff involved in malaria diagnosis and treatment. Only 66.7% BHUs, 47.4% RHCs, 33.3% THQs and 50.0% DHQs had a medical officer. The strength of
75 malaria related staff involved in diagnosis and care of malaria in these health facilities was better as 72% BHUs, 79% RHCs, 100% THQs and 92.9% DHQs had malaria staff.
When the medical officer and staff position in 2012 was compared with 2013, the staff and medical officer’s strength was much lower in 2012.
Among provinces, there was a substantial improvement in the number of medical officers and staff involved in malaria related activities especially in KPK and FATA (Figures 26 and 27).
Figure 26: Staff working for malaria at Health facility by Province (year 2013)
120
100
80
60 Percent 40
20
0 MO Staff MO Staff MO Staff MO Staff MO Staff
Sindh Balochistan KPK FATA Total BHU RHC THQ DHQ
76
Figure 27: Staff working for malaria at Health facility by Province (year 2012)
120
100
80
60 Percent 40
20
0 MO Staff MO Staff MO Staff MO Staff MO Staff
Sindh Balochistan KPK FATA Total
BHU RHC THQ DHQ
8.2. EQUIPMENT & SUPPLIES AT HEALTH FACILITIES OF 38 DISTRICTS (2012 -13) Though functional microscopes were available at 84% microscopy centres but amongst the supplies; glass slides and Cedar wood oil were available at 80% sites; distilled water, finger prickers, buffer tablets and methanol were present at only 50% sites. Comparison of equipment and supplies between 2012 and 2013 showed a considerable improvement in 2013 (Tables 45 and 46).
77
Table 45: Equipment and supplies at Microscopy Centres in Year 2012
Func. Glass Giem. Cedar Dist. Buff Meth- Pick- Province District Health Micr slides Stain W. Oil Water Tab. anol ers Facility NOs. 10 14 14 12 6 7 11 14 6 districts 19 % 52.6 73.7 73.7 63.2 31.6 36.8 57.9 73.7 4 districts (R- Nos. 7 11 11 9 4 6 8 11 Sindh 11 07) % 63.6 100.0 100.0 81.8 36.4 54.5 72.7 100.0 2 districts (R- Nos. 3 3 3 3 2 1 3 3 8 10) % 37.5 37.5 37.5 37.5 25.0 12.5 37.5 37.5
No. 19 18 18 18 13 16 18 18 15 districts 38 % 50.0 47.4 47.4 47.4 34.2 42.1 47.4 47.4 9 districts (R- No. 17 17 17 17 12 15 17 17 Balochistan 24 07) % 70.8 70.8 70.8 70.8 50.0 62.5 70.8 70.8 6 districts (R- No. 2 1 1 1 1 1 1 1 14 10) % 14.3 7.1 7.1 7.1 7.1 7.1 7.1 7.1
No. 4 3 3 3 1 0 3 1 7 districts 17 % 23.5 17.6 17.6 17.6 5.9 0.0 17.6 5.9 3 districts (R- No. 1 0 0 0 0 0 0 0 KPK 6 07) % 16.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4 districts (R- No. 3 3 3 3 1 0 3 1 11 10) % 27.3 27.3 27.3 27.3 9.1 0.0 27.3 9.1
No. 7 7 7 7 5 5 7 6 10 districts 18 % 38.9 38.9 38.9 38.9 27.8 27.8 38.9 33.3 3 districts (R- No. 5 5 5 5 5 5 5 5 FATA 7 07) % 71.4 71.4 71.4 71.4 71.4 71.4 71.4 71.4 7 districts (R- No. 2 2 2 2 0 0 2 1 11 10) % 18.2 18.2 18.2 18.2 0.0 0.0 18.2 9.1
No. 40 42 42 40 25 28 39 39 38 districts 92 % 43.5 45.7 45.7 43.5 27.2 30.4 42.4 42.4 19 districts No. 30 33 33 31 21 26 30 33 Total 48 (R-07) % 62.5 68.8 68.8 64.6 43.8 54.2 62.5 68.8 19 districts No. 10 9 9 9 4 2 9 6 44 (R-10) % 22.7 20.5 20.5 20.5 9.1 4.5 20.5 13.6
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Table 46: Equipment and supplies for Microscopy Centres in Year 2013 Health Func. Glass Giem. Ceder Dist. Buff Meth- Pick- Province District Facility Micr slides Stain W. Oil Water Tab. anol ers No. 11 15 15 14 8 3 3 3 6 districts 19 % 57.9 78.9 78.9 73.7 42.1 15.8 15.8 15.8 Sindh No. 7 11 11 10 5 2 3 3 4 districts 11 (R-07) % 63.6 100.0 100.0 90.9 45.5 18.2 27.3 27.3 No. 4 4 4 4 3 1 0 0 2 districts 8 (R-10) % 50.0 50.0 50.0 50.0 37.5 12.5 0.0 0.0 No. 31 29 30 30 15 11 12 14 15 38 districts % 81.6 76.3 78.9 78.9 39.5 28.9 31.6 36.8 9 districts No. 21 19 20 20 14 6 7 8 Balochistan 24 (R-07) % 87.5 79.2 83.3 83.3 58.3 25.0 29.2 33.3 6 districts No. 10 10 10 10 1 5 5 6 14 (R-10) % 71.4 71.4 71.4 71.4 7.1 35.7 35.7 42.9 7 17 No. 17 16 17 16 16 6 3 9 districts
% 100.0 94.1 100.0 94.1 94.1 35.3 17.6 52.9 KPK 3 districts 6 No. 6 6 6 6 6 3 0 6 (R-07)
% 100.0 100.0 100.0 100.0 100.0 50.0 0.0 100.0 4 districts 11 No. 11 10 11 10 10 3 3 3 (R-10)
% 100.0 90.9 100.0 90.9 90.9 27.3 27.3 27.3 10 18 No. 18 17 17 17 15 1 3 14 districts
% 100.0 94.4 94.4 94.4 83.3 5.6 16.7 83.3 FATA 3 districts 7 No. 7 6 6 6 6 1 1 3 (R-07)
% 100.0 85.7 85.7 85.7 85.7 14.3 14.3 42.9 7 districts 11 No. 11 11 11 11 9 0 2 11 (R-10)
% 100.0 100.0 100.0 100.0 81.8 0.0 18.2 100.0 38 92 No. 77 77 79 77 54 21 21 42 districts
% 83.7 83.7 85.9 83.7 58.7 22.8 22.8 45.7 Total 19 districts 48 No. 41 42 43 42 31 12 11 21 (R-07)
% 85.4 87.5 89.6 87.5 64.6 25.0 22.9 43.8 19 districts 44 No. 36 35 36 35 23 9 10 21 (R-10)
% 81.8 79.5 81.8 79.5 52.3 20.5 22.7 47.7
8.3. IN-STOCK POSITION OF ANTI-MALARIAL DRUGS AND LLINS Using the stock register data the availability of antimalarials drugs and LLINs were checked for 2012. Only 51% surveyed facilities had recommended antimalarial drugs in their stock for the treatment of falciparum and vivax malaria (tablet chloroquine, primaquine and ACT along with injectables). Interestingly tablet fansidar was also in stock at many sites. LLINs were in stock at 44.4% facilities (Table 47).
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In 2013, on the day of visit, above 95% of surveyed facilities had recommended antimalarials in stock for the treatment of falciparum and vivax malaria. Tablet Fansidar was still in stock at many sites. LLINS were in stock at 78.8% health facilities on the day of visit. Interprovincial variations were found in the stock of drugs and LLINs (Table 48). Reciprocally when the stock situation of antimalarial drugs was compared in the same month of 2012 as that of 2013, the situation showed a substantial improvement in 2013.
Table 47: Stock position of anti malaria drugs and LLINs (2012) AS AS Fans- Q. Q. Province Districts HF CQ PQ ACT A-L LLINs Tab Inj. idar Tab Inj. 6 districts 39 26 23 20 20 20 27 24 24 19 18 66.7 59.0 51.3 51.3 51.3 69.2 61.5 61.5 48.7 46.2 4 districts 17 14 12 13 13 16 13 13 13 13 Sindh 25 (R-07) 68.0 56.0 48.0 52.0 52.0 64.0 52.0 52.0 52.0 52.0 9 9 8 7 7 11 11 11 6 5 2 districts 14 (R-10) 64.3 64.3 57.1 50.0 50.0 78.6 78.6 78.6 42.9 35.7 55 55 50 53 53 54 49 49 52 50 15 86 districts 64.0 64.0 58.1 61.6 61.6 62.8 57.0 57.0 60.5 58.1 Balochistan 52 52 47 50 50 51 46 46 46 47 9 districts 52
(R-07) 100.0 100.0 90.4 96.2 96.2 98.1 88.5 88.5 88.5 90.4 3 3 3 3 3 3 3 3 6 3 6 districts 34 (R-10) 8.8 8.8 8.8 8.8 8.8 8.8 8.8 8.8 17.6 8.8 12 12 12 12 12 12 12 12 12 12 7 districts 33 36.4 36.4 36.4 36.4 36.4 36.4 36.4 36.4 36.4 36.4 3 districts 0 0 0 0 0 0 0 0 0 0 KPK (R-07) 14 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 12 12 12 12 12 12 12 12 12 12 4 districts 19 (R-10) 63.2 63.2 63.2 63.2 63.2 63.2 63.2 63.2 63.2 63.2 8 8 8 8 8 8 8 8 8 8 10 40 districts 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0 20.0 3 districts 4 4 4 4 4 4 4 4 4 4 FATA 12 (R-07) 33.3 33.3 33.3 33.3 33.3 33.3 33.3 33.3 33.3 33.3 4 4 4 4 4 4 4 4 4 4 7 districts 28 (R-10) 14.3 14.3 14.3 14.3 14.3 14.3 14.3 14.3 14.3 14.3 101 98 90 93 93 101 93 93 91 88 38 198 districts 51.0 49.5 45.5 47.0 47.0 51.0 47.0 47.0 46.0 44.4 19 districts 73 70 63 67 67 71 63 63 63 64 Total 103 (R-07) 70.9 68.0 61.2 65.0 65.0 68.9 61.2 61.2 61.2 62.1 28 28 27 26 26 30 30 30 28 24 19 districts 95 (R-10) 29.5 29.5 28.4 27.4 27.4 31.6 31.6 31.6 29.5 25.3
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Table 48: Stock position of anti Malaria drugs and LLINs in health facilities on the day of visit in 38 districts (2013)
AS AS Fansi- Q. Q. Province Districts HF CQ PQ ACT A-L LLINs Tab Inj. dar Tab Inj.
39 35 38 24 24 22 38 30 33 23 20 6 districts 89.7 97.4 61.5 61.5 56.4 97.4 76.9 84.6 59.0 51.3 4 districts 25 22 24 18 20 18 24 18 21 18 18 Sindh (R-07) 88.0 96.0 72.0 80.0 72.0 96.0 72.0 84.0 72.0 72.0 2 districts 14 13 14 6 4 4 14 12 12 5 2 (R-10) 92.9 100.0 42.9 28.6 28.6 100.0 85.7 85.7 35.7 14.3 86 86 85 68 76 68 86 71 79 69 73 15 districts 100.0 98.8 79.1 88.4 79.1 100.0 82.6 91.9 80.2 84.9 52 52 47 49 46 52 48 51 47 48 Balochistan 9 districts 52 (R-07) 100.0 100.0 90.4 94.2 88.5 100.0 92.3 98.1 90.4 92.3 6 districts 34 34 33 21 27 22 34 23 28 22 25 (R-10) 100.0 97.1 61.8 79.4 64.7 100.0 67.6 82.4 64.7 73.5 33 32 33 23 28 22 32 23 31 24 25 7 districts 97.0 100.0 69.7 84.8 66.7 97.0 69.7 93.9 72.7 75.8
3 districts 14 14 14 13 13 13 13 13 14 14 14 KPK (R-07) 100.0 100.0 92.9 92.9 92.9 92.9 92.9 100.0 100.0 100.0
4 districts 19 18 19 10 15 9 19 10 17 10 11 (R-10) 94.7 100.0 52.6 78.9 47.4 100.0 52.6 89.5 52.6 57.9
40 40 40 39 38 37 40 38 40 37 38 10 districts 100.0 100.0 97.5 95.0 92.5 100.0 95.0 100.0 92.5 95.0 12 12 11 10 9 12 10 12 9 10 FATA 3 districts 12 (R-07) 100.0 100.0 91.7 83.3 75.0 100.0 83.3 100.0 75.0 83.3 7 districts 28 28 28 28 28 28 28 28 28 28 28 (R-10) 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 198 193 196 154 166 149 196 162 183 153 156 38 districts 97.5 99.0 77.8 83.8 75.3 99.0 81.8 92.4 77.3 78.8
19 districts 103 100 102 89 92 86 101 89 98 88 90 Total (R-07) 97.1 99.0 86.4 89.3 83.5 98.1 86.4 95.1 85.4 87.4
19 districts 95 93 94 65 74 63 95 73 85 65 66 (R-10) 97.9 98.9 68.4 77.9 66.3 100.0 76.8 89.5 68.4 69.5
HF=Health Facility; CQ=Chloroquine, PQ=Primaquine. AS=Artesunate; ACT Artesunate combination therapy, A-L- Artesunate Lumifantrine, Q=- Quinine, LLINs= Long Lasting Insecticide treated nets
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8.4. STOCK-OUT POSITION OF ANTI-MALARIALS, RDTS AND LLINS IN PEAK SEASONS OF MALARIA (AUGUST to OCTOBER 2013)
The stock out analysis has been done only for the antimalarial drugs and RDTs supplied through Global Fund support. Out of 198 surveyed facilities, 130 (66%) health facilities were strengthened through Global Fund support.
The stock outs were recorded for the months of August, September and October (peak malaria transmission months) for 2013. Table 49 shows average stock out position of antimalarial drugs and RDTs at these health facilities based on FM2 data. Out of 198 health facilitates, FM2 were received from 124 health facilities. A considerable numbers of FM2 (72 Forms) received from the health facilities had missing information on stock position of antimalarial drugs and RDTs which, remained a major limitation and the results for stock outs should be interperated with caution.
On average minimal stock out for 3 months (Aug-Oct) was observed for ACT (0.3%) followed by CQ (2.7%) and PQ (2.7%). Injection Artesunate and RDTs showed higher stock outs of 9.2% and 6.8% respectively (Table 49). District and Province wise detail may be seen in appendix. The stock out of LLINs was not analyzed because nets were continuously distributed from few selected health facilities in the UCs. The reported stock out of antimalarial drugs such as fansidar, artesunate tablets and quinine injections distributed by the district health department were recorded but not analyzed for this report.
Table 49: Stock out of anti malarial and RDTs provided through GF R-10 grant during three months (August, September, October) 2013 in 38 districts
Year Districts HF CQ PQ AS Inj. ACT Q. Tab RDT 2013
OOSt 3 (2.5) 4 (3.2) 5 (6.8) 0 (0.0) 2 (2.2) 2 (6.3) Aug 38 districts 198 IA-FM2 120 124 73 116 90 32
OOSt 3 (2.6) 1 (0.9) 5 (7.5) 0 (100) 2 (2.4) 3 (9.4) Sep 38 districts 198 IA-FM2 114 114 67 105 84 32
OOSt 4 (4.4) 4 (4.3) 8 (14.3) 1 (1.3) 5 (7.6) 2 (8.3) Oct 38 districts 198 IA-FM2 91 93 56 80 66 24
Average 3 months of OOSt 3 (2.7) 3 (2.7) 6 (9.2) 0.3 (0.3) 3 (3.7) 2 (6.8) 38 districts IA-FM2 108 110 65 100 80 29
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8.5. MALARIA CASE MANAGEMENT PRACTICES About 93% facilities were performing microscopy and 56% were performing RDTs while, rest were referring suspected cases to other health facilities. Province wise malaria microscopy were performed at all health facilities in FATA and KPK followed by Sindh (93.3%) and Balochistan (86%). Out of 6 (7.2%) facilities that were not performing microscopy, 4 were referring to other health facilities for confirmation of malaria (Table 50).
Table 50: Number of health facilities performing malaria microscopy at RHCs, THQs and DHQs in 38 Districts
Facilities performing If no, how malaria is confirmed Province Districts HF microscopy Yes No Referred Don’t Know 6 districts 15 14 1 0 1 Sindh 4 districts (R-07) 11 11 0 0 0 2 districts (R-10) 4 3 1 0 1 15 districts 36 31 5 1 1 Balochistan 9 districts (R-07) 24 21 3 0 0 6 districts (R-10) 12 10 2 1 1 7 districts 17 17 0 0 0 KPK 3 districts (R-07) 6 6 0 0 0 4 districts (R-10) 11 11 0 0 0 10 districts 16 16 0 0 0 FATA 3 districts (R-07) 5 5 0 0 0 7 districts (R-10) 11 11 0 0 0 38 districts 84 78 (93%) 6 1 2 Total 19 districts (R-07) 46 43 (93.4%) 3 0 0 19 districts (R-10) 38 35 (92.1%) 3 1 2
BHUs diagnose malaria using rapid diagnostic tests. Out of 106 BHUs, only 52 were doing RDTs. Out of these 52 BHUs, only 16 (31%) had trained staff to do the test while, remaining 36 (69%) were doing it without trained staff (Table 51).
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Table 51: Number of health facilities performing RDTs at BHUs in 38 Districts
Facilities performing If no, how malaria is confirmed Province Districts HF RDTS Referred Treat Don’t know Yes No clinically 6 districts 18 12 6 0 3 3 Sindh 4 districts (R-07) 12 6 6 0 3 3 2 districts (R-10) 6 6 0 0 0 0 15 districts 39 26 13 2 5 6 Balochistan 9 districts (R-07) 24 16 8 2 3 3 6 districts (R-10) 15 10 5 0 2 3 7 districts 16 8 8 7 0 1 KPK 3 districts (R-07) 8 1 7 7 0 0 4 districts (R-10) 8 7 1 0 0 1 10 districts 21 7 14 12 0 2 FATA 3 districts (R-07) 5 2 3 2 0 1 7 districts (R-10) 16 5 11 10 0 1 38 districts 94 53 41 21 8 12 Total 19 districts (R-07) 49 25 24 11 6 7 19 districts (R-10) 45 28 17 10 2 5
8.5.1. Treatment of clinical malaria When both microscopy and RDTs are not done and yet antimalarials are given on clinical suspicion then these cases are called clinically treated cases. Out of 198 health facilities data for clinically treated cases was available at 159 sites (80.3%). Maximum health facilities (93.7%) were using chloroquine for the treatment of clinical malaria followed by Primaquine in (14.5%). Other prescriptions included tablet artesunate or ACT to Injection quinine (Table 52). Within Provinces, tablet chloroquine was mostly (100%) prescribed in KPK, FATA and Balochistan (95.1%). In Sindh this percentage dropped to 75%.
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Table 52: Treatment of clinical malaria HF with Total AS As Fancs- Q Q Province District information CQ PQ ACT A-L HF Tab Inj. dar Tab Inj. available
39 21 6 1 2 0 0 1 2 1 6 districts 28 75.0 21.4 3.6 7.1 0.0 0.0 3.6 7.1 3.6 25 15 4 1 2 0 0 1 2 1 Sindh 4 districts 15 (R-07) 100.0 26.7 6.7 13.3 0.0 0.0 6.7 13.3 6.7
2 districts 14 13 6 2 0 0 0 0 0 0 0 (R-10) 46.2 15.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0
86 61 58 16 7 7 1 16 1 10 3 15 districts 95.1 26.2 11.5 11.5 1.6 26.2 1.6 16.4 4.9
52 36 15 7 7 1 12 1 8 1 Balochistan 9 districts 36 (R-07) 100.0 41.7 19.4 19.4 2.8 33.3 2.8 22.2 2.8
6 districts 34 25 22 1 0 0 0 4 0 2 2 (R-10) 88.0 4.0 0.0 0.0 0.0 16.0 0.0 8.0 8.0
33 32 32 0 0 0 0 0 0 0 0 7 districts 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
14 13 0 0 0 0 0 0 0 0 KPK 3 districts 13 (R-07) 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
4 districts 19 19 19 0 0 0 0 0 0 0 0 (R-10) 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
40 38 38 1 0 0 0 0 0 0 0 10 districts 100.0 2.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0
12 10 1 0 0 0 0 0 0 0 FATA 3 districts 10 (R-07) 100.0 10.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
7 districts 28 28 28 0 0 0 0 0 0 0 0 (R-10) 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
198 159 149 23 8 9 1 16 2 12 4 38 districts 93.7 14.5 5.0 5.7 0.6 10.1 1.3 7.5 2.5
103 74 20 8 9 1 12 2 10 2 Total 19 districts 74 (R-07) 100.0 27.0 10.8 12.2 1.4 16.2 2.7 13.5 2.7
19 districts 95 85 75 3 0 0 0 4 0 2 2 (R-10) 88.2 3.5 0.0 0.0 0.0 4.7 0.0 2.4 2.4
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8.5.2. Treatment and referral of uncomplicated and complicated malaria cases as per guidelines Out of 198 health facilities, data on treatment of uncomplicated cases from FM2 was available only from 73 health facilities whereas for referral of complicated cases, the data was available from 174 facilities. Out of 73 health facilities, 66 (90%) were following national guidelines however, 7 facilities (2 in Sindh and 5 in Balochistan) were not following the guidelines.
Patients with complicated malaria were referred to other treatment sites by 73% RHCs or BHUs after giving some basic treatment (Table 53).
Table 53 : Uncomplicated Malaria cases treated as per guidelines Malaria cases (uncomplicated) No, of Patients treated as per No. of Patients not treated as guide lines per guide lines Province District Total HF HF treating patients PF PV Mixed Clinical HF PF PV Mixed Clinical as per guidelines 6 districts 39 17 146 833 56 267 2 12 9 0 0 4 districts 25 10 Sindh (R-07) 49 438 15 267 2 12 9 0 0 2 districts 14 7 (R-10) 97 395 41 0 0 0 0 0 0 15 districts 86 20 236 7 14 0 5 7 1 0 0 9 districts 52 10 Balochistan (R-07) 66 7 13 0 3 7 1 0 0 6 districts 34 10 (R-10) 170 0 1 0 2 0 0 0 0 7 districts 33 28 323 4180 101 0 0 0 0 0 0 3 districts 14 10 KPK (R-07) 132 1917 11 0 0 0 0 0 0 4 districts 19 18 (R-10) 191 2263 90 0 0 0 0 0 0 10 districts 40 1 3 0 0 0 0 0 0 0 0 3 districts 12 1 FATA (R-07) 3 0 0 0 0 0 0 0 0 7 districts 28 0 (R-10) 0 0 0 0 0 0 0 0 0 38 districts 198 66 708 5020 171 267 7 19 10 0 0 19 districts 103 31 Total (R-07) 250 2362 39 267 5 19 10 0 0 19 districts 95 35 (R-10) 458 2658 132 0 2 0 0 0 0 THF = Total health facility HF = Health facility,
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Treatment given at the time of referral, mostly included injectables like quinine (5.2%) and artesunate (14.4%) while, for oral therapy, chloroquine (57.5%), primaquine (4%) and tab. quinine (0.6%) were given (Table 54).
Table 54: Treatment given at the time of referral of complicated malaria cases by province.
Total Reporting Province District Referred CQ PQ Inj.AS Fancidar ACT Tab. Q Inj. Q HF HF
6 districts 39 38 19 18 0 1 0 0 0 2 50.0 47.4 0.0 2.6 0.0 0.0 0.0 5.3 Sindh 4 districts 18 17 0 1 0 0 0 2 (R-07) 25 24 75.0 70.8 0.0 4.2 0.0 0.0 0.0 8.3 2 districts 1 1 0 0 0 0 0 0 (R-10) 14 14 7.1 7.1 0.0 0.0 0.0 0.0 0.0 0.0 15 54 37 6 9 7 2 1 4 districts 86 70 77.1 52.9 8.6 12.9 10.0 2.9 1.4 5.7 Balochistan 9 districts 39 25 6 6 6 2 0 1 (R-07) 52 47 83.0 53.2 12.8 12.8 12.8 4.3 0.0 2.1 6 districts 15 12 0 3 1 0 1 3 (R-10) 34 23 65.2 52.2 0.0 13.0 4.3 0.0 4.3 13.0 7 24 17 0 10 0 0 0 0 districts 33 28 85.7 60.7 0.0 35.7 0.0 0.0 0.0 0.0 KPK 3 districts 10 13 0 1 0 0 0 0 (R-07) 14 13 76.9 100.0 0.0 7.7 0.0 0.0 0.0 0.0 4 districts 14 4 0 9 0 0 0 0 (R-10) 19 15 93.3 26.7 0.0 60.0 0.0 0.0 0.0 0.0 10 30 28 1 5 0 0 0 3 districts 40 38 78.9 73.7 2.6 13.2 0.0 0.0 0.0 7.9 FATA 3 districts 8 4 1 2 0 0 0 3 (R-07) 12 11 72.7 36.4 9.1 18.2 0.0 0.0 0.0 27.3 7 districts 22 24 0 3 0 0 0 0 (R-10) 28 27 81.5 88.9 0.0 11.1 0.0 0.0 0.0 0.0 38 127 100 7 25 7 2 1 9 districts 198 174 73.0 57.5 4.0 14.4 4.0 1.1 0.6 5.2 Total 19 districts 75 59 7 10 6 2 0 6 (R-07) 103 95 78.9 62.1 7.4 10.5 6.3 2.1 0.0 6.3 19 districts 52 41 0 15 1 0 1 3 (R-10) 95 79 65.8 51.9 0.0 19.0 1.3 0.0 1.3 3.8
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Figure 28 shows availability of guidelines at health facilities in 2012 and 2013. There was a marked improvement in the availability of guidelines at the health facilities in 2013 as compared to 2012.
Figure 28: Facilities having national malaria guidelines in 2012 and 2013
Table 55 shows the categories of health facilities where complicated malaria cases were referred. Overall 83% facilities referred complicated cases to DHQ and 13.2% to tertiary care hospitals. Table 55: Type of health facilities where complicated malaria cases are referred Facilities where complicated malaria cases were referred THQ(bring Reportin Province District Tota DHQ DHQ column Tertiary care g HF l HF here)
No. % No. % No. %
Sindh 6 districts 39 21 11 52.4 5 23.8 5 23.8 4 districts (R-07) 25 20 10 50.0 5 25.0 5 25.0 2 districts (R-10) 14 1 1 100.0 0 0.0 0 0.0 Balochista 15 districts 86 75 61 81.3 1 1.3 13 17.3 n 9 districts (R-07) 52 50 41 82.0 0 0.0 9 18.0
6 districts (R-10) 34 25 20 80.0 1 4.0 4 16.0 KPK 7 districts 33 29 29 100.0 0 0.0 0 0.0 3 districts (R-07) 14 12 12 100.0 0 0.0 0 0.0 4 districts (R-10) 19 17 17 100.0 0 0.0 0 0.0 FATA 10 districts 40 34 31 91.2 0 0.0 3 8.8 3 districts (R-07) 12 11 8 72.7 0 0.0 3 27.3 7 districts (R-10) 28 23 23 100.0 0 0.0 0 0.0 Total 38 districts 198 159 132 83.0 6 3.8 21 13.2 19 districts (R-07) 103 93 71 76.3 5 5.4 17 18.3 19 districts (R-10) 95 66 61 92.4 1 1.5 4 6.1
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8.5.3. Time elapse between smear taken and result received All health facilities reported that they receive malaria microscopy results on the same day of the test. All except 2 facilities in Balochistan were starting treatment of malaria on the day of diagnosis.
8.5.4. Health facilities designated as LLINs distribution points Out of GF supported facilities 78.9% were designated as distribution point for LLINs. Maximum facilities (100%) were designated as distribution points for LLINs in KPK followed by Sindh, Balochistan and FATA (Figure-29).
Figure 29: Surveyed health facilities designated as distribution point for LLINs (2013)
8.6. SKILL DEVELOPMENT Data on skill development for 2012-13 was available in 189 out of 198 health facilities. In 2013 61.4% facilities had medical officers trained on case management guidelines for uncomplicated malaria and 60.3% on complicated malaria (Figure 30). Maximum percentage of health facilities with trained MOs on uncomplicated and complicated guidelines were from KPK (100%) and FATA (>80%). Overall 56% of the facilities had trained staff on microscopy, 62% on RDTs, 74% on MIS and 47% on LLIN distribution strategy. Again maximum percentage of health facilities had trained staff on malaria microscopy in KPK and FATA followed by Balochistan and Sindh (Table 56).
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Table 56: Staff trained on National malaria guidelines in surveyed facilities of 38 districts (2013)
Health Medical Officer Facility Staff Total Province District Facility with Uncomplicated Complicated HF Microscopy RDTs MIS LLINs trained staff Malaria Malaria 15 12 9 12 16 10 6 districts 39 39 38.5 30.8 23.1 30.8 41.0 25.6 4 districts 8 6 8 5 8 5 Sindh 25 25 (R-07) 32.0 24.0 32.0 20.0 32.0 20.0 2 districts 7 6 1 7 8 5 14 14 (R-10) 50.0 42.9 7.1 50.0 57.1 35.7 35 39 35 44 59 46 15 districts 86 80 43.8 48.8 43.8 55.0 73.8 57.5 9 districts 19 23 21 25 32 26 52 52 Balochistan (R-07) 36.5 44.2 40.4 48.1 61.5 50.0 6 districts 16 16 14 19 27 20 (R-10) 34 28 57.1 57.1 50.0 67.9 96.4 71.4 32 32 27 29 31 20 7 districts 33 32 100.0 100.0 84.4 90.6 96.9 62.5 3 districts 13 13 12 12 13 10 KPK 14 13 (R-07) 100.0 100.0 92.3 92.3 100.0 76.9 4 districts 19 19 15 17 18 10 19 19 (R-10) 100.0 100.0 78.9 89.5 94.7 52.6 34 31 34 32 35 12 10 districts 40 38 89.5 81.6 89.5 84.2 92.1 31.6 3 districts 10 7 10 6 11 6 FATA 12 11 (R-07) 90.9 63.6 90.9 54.5 100.0 54.5 7 districts 24 24 24 26 24 6 28 27 (R-10) 88.9 88.9 88.9 96.3 88.9 22.2 116 114 105 117 141 88 38 districts 198 189 61.4 60.3 55.6 61.9 74.6 46.6 19 districts 50 49 51 48 64 47 Total 103 101 (R-07) 49.5 48.5 50.5 47.5 63.4 46.5 19 districts 66 65 54 69 77 41 95 88 (R-10) 75.0 73.9 61.4 78.4 87.5 46.6
In 2012, 23 % health facilities had medical officers trained on case management guidelines for uncomplicated malaria and 19% on complicated malaria. Situation was worst in KPK and FATA. Overall 21% facilities had trained staff on microscopy, 19.6% on RDTs, 24.3% on MIS and 10% on LLINs. Maximum health facilities had trained staff on malaria microscopy in KPK and FATA followed by Balochistan and Sindh (Table 57).
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Table 57: Staff trained on national malaria guidelines in 38 districts (2012)
Health Medical Officer Facility Staff Facility Total Province District with Uncomplicated Complicated HF Microscopy RDTs MIS LLINs trained Malaria Malaria staff 18 11 15 11 16 10 6 districts 39 39 46.2 28.2 38.5 28.2 41.0 25.6 Sindh 4 districts 10 7 11 6 8 5 (R-07) 25 25 40.0 28.0 44.0 24.0 32.0 20.0 2 districts 8 4 4 5 8 5 (R-10) 14 14 57.1 28.6 28.6 35.7 57.1 35.7 24 22 19 22 27 18 15 districts 86 80 30.0 27.5 23.8 27.5 33.8 22.5 Balochistan 9 districts 24 22 19 22 27 18 (R-07) 52 52 46.2 42.3 36.5 42.3 51.9 34.6 6 districts 0 0 0 0 0 0 (R-10) 34 28 0.0 0.0 0.0 0.0 0.0 0.0 0 0 0 0 0 0 7 districts 33 32 0.0 0.0 0.0 0.0 0.0 0.0 KPK 3 districts 0 0 0 0 0 0 (R-07) 14 13 0.0 0.0 0.0 0.0 0.0 0.0 4 districts 0 0 0 0 0 0 (R-10) 19 19 0.0 0.0 0.0 0.0 0.0 0.0 3 3 6 4 3 2 10 districts 40 38 7.9 7.9 15.8 10.5 7.9 5.3 FATA 3 districts 3 0 3 2 3 2 (R-07) 12 11 27.3 0.0 27.3 18.2 27.3 18.2 7 districts 0 3 3 2 0 0 (R-10) 28 27 0.0 11.1 11.1 7.4 0.0 0.0 45 36 40 37 46 30 38 districts 198 189 23.8 19.0 21.2 19.6 24.3 15.9
19 districts 37 29 33 30 38 25 Total 103 101 (R-07) 36.6 28.7 32.7 29.7 37.6 24.8
19 districts 8 7 7 7 8 5 95 88 (R-10) 9.1 8.0 8.0 8.0 9.1 5.7
When compared with 2012 there has been a marked improvement in the availability of trained staff at the health facilities in 2013 (Figure 30).
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Figure 30: Staff trained on national malaria guidelines in surveyed facilities of 38 districts (year 2012 & 2013) - Overall
LLINs (Staff) 46.6 15.9
MIS (Staff) 74.6 24.3
RDTs (Staff) 61.9 19.6
Microscopy (Staff) 55.6 21.2 Year 2013 Year 2012
Complicated Malaria (MO) 60.3 19.0
Uncomplicated Malaria (MO) 61.4 23.8
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 Percent
8.7. MALARIA SITUATION IN HEALTH FACILITIES IN 38 DISTRICTS (2012-13) Data was collected from selected health facilities performing microscopy and RDTs in 38 districts to compare the trend over two years, comparing same months regarding out patients attendance, suspected malaria cases, slides prepared, total malaria cases registered and parasite species.
Figure 31 presents trend in OPD, suspected malaria cases and number of slides prepared. There were 12,584 additional suspected malaria cases reported in 2013 as compared to 2012. The number of slides prepared also increased by about 7.5% (15,082 additional slides prepared). This shows that there has been a reasonable increase in suspect identification and slide examination in the microscopy centres in the 38 target districts.
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Figure 31: Suspected malaria cases and slide examination and microscopy in 2012- 2013 (Jan to Oct.)
There was a decrease in the overall slide positivity rate in 2013 (13.3%) as compared to 2012 (16.8%). About 80.3% were diagnosed as vivax and 19.2% as falciparum malaria cases while, 0.5% were mixed infections. The proportion of Plasmodium vivax to P. falciparum remained almost same over the two years (Figure-32).
Figure 32: Slide positivity rate and PV to PF ratio in 2012 & 2013
Malaria positivity rate in (%) 93
Figure 33 presents the trend in facilities that were performing RDTs. There were 7469 additional suspected malaria cases reported in 2013 as compared to 2012. The number of RDTs done also doubled as compared to 2012 (13,717 additional RDTs done). Figure 33: Suspect identification and RDTs done at the RDT Centres in 2012 & 2013 (Jan to Oct.)
The RDT positivity rate did not show any difference over the two years; however in 2012 about 70% were diagnosed as falciparum and 27% as vivax malaria and this proportion almost reversed in 2013 where vivax malaria was reported as 72% and falciparum as 27% (Figure 34). This situation needs more in depth epidemiological analysis. Similarly percentage of mixed infections increased 3 times in 2013 as compared to 2012.
Figure 34: Positive malaria cases on RDTs (2012 & 2013)
Malaria positivity rate in (%)
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8.8. SEASONAL VARIATION OF MALARIA BY PROVINCE (2012-13)
Figure 35 shows trend in the proportion of malaria cases reported on monthly basis in four provinces. Although number of malaria cases showed an increase from June to October but true peaks were not visible. This trend was almost similar in 2012 and 2013.
Figure 35: Trend in the proportion of malaria cases reported by the health facilities
Sindh Balochistan
KPK FATA
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9.
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9. IMPLICATIONS OF MIS RESULTS
Some of the key implications of the survey are given below:
1. Almost 28% respondents were women demonstrating the role of women in the decision making. Interventions can therefore, be targeted involving women to have a better impact. 2. 13% population below five years is vulnerable to malaria and need full coverage by malaria control interventions. 3. Almost two-third of the houses (72%) was Kacha houses and this has major implication in term of IRS. 4. The BCC strategies should target electronic media such as TV being the prominent possession in the households. Similarly excessive availability of mobile in the households could be used as a future strategy option for introducing m-health in malaria control. 5. Role of LHWs in enhancing community awareness about LLINs may be emphasized which can be more cost effective. 6. Knowledge about malaria prevention is sub optimal and need to be improved. 7. About 28% of the population self treated malaria using either allopathic (78.8%) or homeopathic (14.4%) medicines. This shows that acute problem such as fever is mainly managed through allopathic medicines. However, the utilization of public sector facilities is only 50% for treatment of fever. The services at government health facilities need to be strengthened so that community uses them. 8. Over all 34% households reported having at least one LLIN. This is far behind the target of universal coverage i.e. 2.5 nets per household. 9. IRS is a very powerful but costly vector control intervention and needs to be used in those Union Councils where the SPR is >5. The survey showed that there is considerable number of UCs having SPR > 5 especially in FATA and some districts of Balochistan. In order to have judicious and effective use of IRS the districts and UCs need to be comprehensively mapped to identify high risk pockets. However, the Malaria Control Programme mainly uses API as the main indicator to categorize high risk districts. 10. There is a high proportion of cases (13%) with mixed infection diagnosed on RDTs. This requires clearly spelled out policies for the treatment of such cases. Data on fever cases is regularly reported through district health information system (DHIS) and also by Pakistan
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Demographic and Health Survey (PDHS) which need to be considered while, planning the procurement of RDTs for health facilities. 11. The positive parasitaemia in asymptomatic cases is important for planning control and elimination strategies and interventions. Based on the data presented in table 43, we can roughly estimate malaria cases in 19 districts which, could be 0.6 million including both fever and non-fever cases. 12. Historically Plasmodium falciparum has been higher in the high risk districts. However, the trends exhibited by the health facility data suggests a dramatic change in the PV:PF in the year 2013 as compared to 2012. The change of epidemiology regarding predominance of Plasmodium vivax and much lowered proportion of falciparum need to be further studied through epidemiological and entomological studies.
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10. APPENDIX-A: DISTRICT WISE DATA
10.1. HOUSEHOLD POPULATION AND CHARACTERISTICS Table 58 Respondents (household) by gender in 38 districts House- Male Female Districts Round hold No. % No. % Tharparkar/Mithi 7 250 233 93.2 17 6.8 Khairpur 7 400 239 59.8 161 40.3 Thatta 7 349 226 64.8 123 35.2 Dadu 7 391 385 98.5 6 1.5 Tando Allah Yar 10 294 104 35.4 190 64.6 Mirpurkhas 10 397 138 34.8 259 65.2 Zhob/Sheran 7 249 9 3.6 240 96.4 Noushki 7 200 180 90.0 20 10.0 Gawadar 7 249 193 77.5 56 22.5 Kech 7 300 11 3.7 289 96.3 Sibi/Harnai 7 250 151 60.4 99 39.6 Kila Saifullah 7 248 248 100.0 0 0.0 Nasirabad 7 249 116 46.6 133 53.4 Loralai 7 234 126 53.8 108 46.2 Mastung 7 241 175 72.6 66 27.4 Panjgur 10 300 299 99.7 1 0.3 Kharan 10 220 204 92.7 16 7.3 Chaghi 10 250 238 95.2 12 4.8 Washhuk 10 188 170 90.4 18 9.6 Pishin 10 300 173 57.7 127 42.3 Musakhel 10 250 250 100.0 0 0.0 Lakki Marwat 7 300 132 44.0 168 56.0 Bannu 7 349 171 49.0 178 51.0 Mardan 7 400 177 44.3 223 55.8 Tank 10 299 225 75.3 74 24.7 Charsada 10 399 335 84.0 64 16.0 Nowshera 10 403 303 75.2 100 24.8 D.I.Khan 10 350 267 76.3 83 23.7 Kurram 7 300 300 100.0 0 0.0 Khyber 7 300 300 100.0 0 0.0 Bajaur 7 300 299 99.7 1 0.3 North Waziristan 10 247 247 100.0 0 0.0 Orakzai 10 249 246 98.8 3 1.2 Mohmand 10 300 154 51.3 146 48.7 South Waziristan 10 300 275 91.7 25 8.3 FR Peshawar/Kohat 10 249 218 87.6 31 12.4 FR Bannu/Lakki 10 150 117 78.0 33 22.0 FR Tank/DI Khan 10 200 200 100.0 0 0.0 Total 10904 7835 71.9 3069 28.1
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Table 59: Respondents by age in 38 districts Under 15 House- District Round years 15-49 years 50+ years hold No. % No. % No. % Tharparkar/Mithi 7 250 0 0.0 138 55.2 112 44.8 Khairpur 7 400 0 0.0 305 76.3 95 23.8 Thatta 7 349 2 0.6 236 67.6 111 31.8 Dadu 7 391 1 0.3 276 70.6 114 29.2 Tando Allah Yar 10 291 0 0.0 247 84.9 44 15.1 Mirpurkhas 10 397 1 0.3 348 87.7 48 12.1 Zhob/Sheran 7 249 1 0.4 210 84.3 38 15.3 Noushki 7 200 2 1.0 103 51.5 95 47.5 Gawadar 7 249 0 0.0 173 69.5 76 30.5 Kech 7 300 0 0.0 225 75.0 75 25.0 Sibi/Harnai 7 250 4 1.6 187 74.8 59 23.6 Kila Saifullah 7 248 0 0.0 167 67.3 81 32.7 Nasirabad 7 249 1 0.4 242 97.2 6 2.4 Loralai 7 234 7 3.0 171 73.1 56 23.9 Mastung 7 241 1 0.4 171 71.0 69 28.6 Panjgur 10 299 0 0.0 205 68.6 94 31.4 Kharan 10 204 1 0.5 150 73.5 53 26.0 Chaghi 10 250 6 2.4 176 70.4 68 27.2 Washhuk 10 188 1 0.5 157 83.5 30 16.0 Pishin 10 300 114 38.0 142 47.3 44 14.7 Musakhel 10 250 1 0.4 167 66.8 82 32.8 Lakki Marwat 7 300 0 0.0 243 81.0 57 19.0 Bannu 7 349 2 0.6 255 73.1 92 26.4 Mardan 7 400 1 0.3 303 75.8 96 24.0 Tank 10 299 4 1.3 211 70.6 84 28.1 Charsada 10 398 4 1.0 231 58.0 163 41.0 Nowshera 10 403 2 0.5 276 68.5 125 31.0 D.I.Khan 10 350 3 0.9 265 75.7 82 23.4 Kurram 7 300 0 0.0 259 86.3 41 13.7 Khyber 7 300 0 0.0 230 76.7 70 23.3 Bajaur 7 300 0 0.0 208 69.3 92 30.7 North Wazirastan 10 247 0 0.0 218 88.3 29 11.7 Orakzai 10 249 1 0.4 176 70.7 72 28.9 Mohmand 10 300 0 0.0 237 79.0 63 21.0 South Waziristan 10 300 10 3.3 237 79.0 53 17.7 FR Peshawar / Kohat 10 249 1 0.4 197 79.1 51 20.5 FR Bannu/Lakki 10 150 0 0.0 108 72.0 42 28.0 FR Tank/DI Khan 10 200 1 0.5 150 75.0 49 24.5 Total 10883 172 1.6 8000 73.5 2711 24.9 (Age not known in 21 households)
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10.2. HOUSEHOLD POPULATION BY SIZE, AGE AND GENDER Table 60: Households with population and size in 38 districts Average Districts Round Household Individuals Household size Sindh Tharparkar/Mithi 7 250 1509 6.0 Khairpur 7 400 3002 7.5 Thatta 7 349 1877 5.4 Dadu 7 391 2242 5.7 Tando Allah Yar 10 294 1600 5.4 Mirpurkhas 10 397 1999 5.0 Balochistan Zhob/Sheran 7 249 1615 6.5 Noushki 7 200 1560 7.8 Gawadar 7 249 1252 5.0 Kech 7 300 1600 5.3 Sibi/Harnai 7 250 1729 6.9 Kila Saifullah 7 248 1710 6.9 Nasirabad 7 249 1440 5.8 Loralai 7 234 1983 8.5 Mastung 7 241 1445 6.0 Panjgur 10 300 1879 6.3 Kharan 10 220 1324 6.0 Chaghi 10 250 1381 5.5 Washhuk 10 188 790 4.2 Pishin 10 300 1287 4.3 Musakhel 10 250 1469 5.9 KPK Lakki Marwat 7 300 1820 6.1 Bannu 7 349 2649 7.6 Mardan 7 400 2960 7.4 Tank 10 299 2032 6.8 Charsada 10 399 2856 7.2 Nowshera 10 403 2288 5.7 D.I.Khan 10 350 2096 6.0 FATA Kurram 7 300 1453 4.8 Khyber 7 300 1846 6.2 Bajaur 7 300 2961 9.9 North Wazirastan 10 247 1171 4.7 Orakzai 10 249 1732 7.0 Mohmand 10 300 2214 7.4 South Waziristan 10 300 1921 6.4 FR 10 249 1459 5.9 Peshawar/Kohat FR Bannu/Lakki 10 150 982 6.5 FR Tank/DI Khan 10 200 838 4.2 Total 10904 67971 6.2
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Table 61: District wise population by Age Under 5-14 years 15-49 years 50 + years Subject Round 5 years No. % No. % No. % No. % Tharparkar / Mithi 1509 7 156 10.3 459 30.4 707 46.9 187 12.4 Khairpur 3002 7 397 13.2 910 30.3 1450 48.3 245 8.2 Thatta 1877 7 219 11.7 547 29.1 915 48.7 196 10.4 Dadu 2242 7 317 14.1 649 28.9 1064 47.5 212 9.5 Tando Allah Yar 1596 10 200 12.5 501 31.3 785 49.1 110 6.9 Mirpurkhas 1999 10 317 15.9 580 29.0 969 48.5 133 6.7 Zhob / Sheran 1615 7 138 8.5 477 29.5 902 55.9 98 6.1 Noushki 1560 7 138 8.8 415 26.6 818 52.4 189 12.1 Gawadar 1252 7 155 12.4 357 28.5 591 47.2 149 11.9 Kech 1600 7 197 12.3 425 26.6 773 48.3 205 12.8 SibI / Harnai 1729 7 210 12.1 409 23.7 961 55.6 149 8.6 Kila Saifullah 1710 7 298 17.4 608 35.6 642 37.5 162 9.5 Nasirabad 1440 7 258 17.9 549 38.1 612 42.5 21 1.5 Loralai 1983 7 329 16.6 605 30.5 874 44.1 175 8.8 Mastung 1445 7 166 11.5 369 25.5 763 52.8 147 10.2 Panjgur 1876 10 176 9.4 473 25.2 1066 56.7 161 8.6 Kharan 1303 10 204 15.4 414 31.3 587 44.3 98 7.4 Chaghi 1381 10 210 15.2 428 31.0 637 46.1 106 7.7 Washhuk 790 10 93 11.8 225 28.5 424 53.7 48 6.1 Pishin 1287 10 152 11.8 427 33.2 627 48.7 81 6.3 Musakhel 1469 10 237 16.1 467 31.8 633 43.1 132 9.0 Lakki Marwat 1820 7 247 13.6 585 32.1 834 45.8 154 8.5 Bannu 2649 7 334 12.6 681 25.7 1334 50.4 300 11.3 Mardan 2960 7 371 12.5 848 28.6 1425 48.1 316 10.7 Tank 2032 10 250 12.3 600 29.5 990 48.7 192 9.4 Charsada 2843 10 343 12.0 785 27.5 1377 48.2 338 11.8 Nowshera 2284 10 342 14.9 586 25.6 1102 48.2 254 11.1 D.I.Khan 2096 10 294 14.0 638 30.4 972 46.4 192 9.2 Kurram 1453 7 198 13.6 396 27.3 794 54.6 65 4.5 Khyber 1846 7 235 12.7 521 28.2 949 51.4 141 7.6 Bajaur 2961 7 331 11.2 793 26.8 1693 57.2 144 4.9 North Wazirastan 1171 10 208 17.8 386 33.0 528 45.1 49 4.2 Orakzai 1732 10 241 13.9 549 31.7 820 47.3 122 7.0 Mohmand 2214 10 361 16.3 726 32.8 934 42.2 193 8.7 South Waziristan 1919 10 108 5.6 463 24.1 1237 64.4 111 5.8 FR Peshawar/Kohat 1456 10 162 11.1 451 30.9 710 48.7 133 9.1 FR Bannu/Lakki 982 10 144 14.7 295 30.0 461 46.9 82 8.4 FR Tank/DI Khan 838 10 116 13.8 346 41.3 318 37.9 58 6.9 Total 67921 8852 13.0 19943 29.3 33278 49.0 5848 8.6
Age not recorded in 50 subjects
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Table 62: District wise population by Gender
Male Female Districts Round Subject No. % No. % Tharparkar/Mithi 7 1509 817 54.1 692 45.9 Khairpur 7 3002 1552 51.7 1450 48.3 Thatta 7 1877 967 51.5 910 48.5 Dadu 7 2242 1167 52.1 1075 47.9 Tando Allah Yar 10 1600 841 52.6 759 47.4 Mirpurkhas 10 1999 1048 52.4 951 47.6 Zhob/Sheran 7 1615 882 54.6 733 45.4 Noushki 7 1560 813 52.1 747 47.9 Gawadar 7 1252 660 52.7 592 47.3 Kech 7 1600 825 51.6 775 48.4 Sibi/Harnai 7 1729 886 51.2 843 48.8 Kila Saifullah 7 1710 898 52.5 812 47.5 Nasirabad 7 1440 775 53.8 665 46.2 Loralai 7 1983 1043 52.6 940 47.4 Mastung 7 1445 764 52.9 681 47.1 Panjgur 10 1879 1084 57.7 795 42.3 Kharan 10 1324 694 52.4 630 47.6 Chaghi 10 1381 732 53.0 649 47.0 Washhuk 10 790 403 51.0 387 49.0 Pishin 10 1287 629 48.9 658 51.1 Musakhel 10 1469 791 53.8 678 46.2 Lakki Marwat 7 1820 1008 55.4 812 44.6 Bannu 7 2649 1375 51.9 1274 48.1 Mardan 7 2960 1525 51.5 1435 48.5 Tank 10 2032 999 49.2 1033 50.8 Charsada 10 2856 1451 50.8 1405 49.2 Nowshera 10 2288 1134 49.6 1154 50.4 D.I.Khan 10 2096 1036 49.4 1060 50.6 Kurram 7 1453 842 57.9 611 42.1 Khyber 7 1846 1097 59.4 749 40.6 Bajaur 7 2961 1606 54.2 1355 45.8 North Waziristan 10 1171 780 66.6 391 33.4 Orakzai 10 1732 970 56.0 762 44.0 Mohmand 10 2214 1158 52.3 1056 47.7 South Waziristan 10 1921 1249 65.0 672 35.0 FR Peshawar/Kohat 10 1459 810 55.5 649 44.5 FR Bannu/Lakki 10 982 509 51.8 473 48.2 FR Tank/DI Khan 10 838 590 70.4 248 29.6 Total 67971 36410 53.6 31561 46.4
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Table 63: Population by age and Gender in 38 GF supported districts (pyramid) Male Female Total Age in years No. % No. % No. % Under 5 4516 12.4 4336 13.7 8852 13.0 5-9 5670 15.6 4876 15.5 10546 15.5 10-14 5195 14.3 4202 13.3 9397 13.8 15-19 3808 10.5 3119 9.9 6927 10.2 20-24 2907 8.0 2896 9.2 5803 8.5 25-29 2921 8.0 2955 9.4 5876 8.7 30-34 2464 6.8 2259 7.2 4723 7.0 35-39 2207 6.1 1881 6.0 4088 6.0 40-44 1804 5.0 1556 4.9 3360 4.9 45-49 1403 3.9 1098 3.5 2501 3.7 50-54 1103 3.0 892 2.8 1995 2.9 55-59 707 1.9 519 1.6 1226 1.8 60 + 1663 4.6 964 3.1 2627 3.9 Total 36368 100.0 31553 100.0 67921 100.0 (Age not known in 50 individuals)
Table 64: Province and district wise surveyed population by Age (years) Under 5 15-49 Total 5-14 years ≥ 50 years Province Districts years years Individuals No. % No. % No. % No. %
6 districts 12225 1606 13.1 3646 29.8 5890 48.2 1083 8.9 Sindh 4 districts (R-07) 8630 1089 12.6 2565 29.7 4136 47.9 840 9.7
2 districts (R-10) 3595 517 14.4 1081 30.1 1754 48.8 243 6.8 15 districts 22440 2961 13.2 6648 29.6 10910 48.6 1921 8.6 Balochistan 9 districts (R-07) 14334 1889 13.2 4214 29.4 6936 48.4 1295 9.0
6 districts (R-10) 8106 1072 13.2 2434 30.0 3974 49.0 626. 7.7 7 districts 16684 2181 13.1 4723 28.3 8034 48.2 1746 10.5 KPK 3 districts (R-07) 7429 952 12.8 2114 28.5 3593 48.4 770 10.4
4 districts (R-10) 9255 1229 13.3 2609 28.2 4441 48.0 976 10.5 10 districts 16572 2104 12.7 4926 29.7 8444 51.0 1098 6.6 FATA 3 districts (R-07) 6260 764 12.2 1710 27.3 3436 54.9 350 5.6
7 districts (R-10) 10312 1340 13.0 3216 31.2 5008 48.6 748 7.3 38 districts 67921 8852 13.0 19943 29.4 33278 49.0 5848 8.6 Total 19 districts (R-07) 36653 4694 12.8 10603 28.9 18101 49.4 3255 8.9 19 districts (R-10) 31268 4158 13.3 9340 29.9 15177 48.5 2593 8.3
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10.3. PREGNANT WOMEN BY AGE Table 65: Pregnant women with Reproductive age in Round-7 and Roud-10 districts
Age 15-29 years Age 30-39 years Age 40-49 years Total District Round Rep. Pregnant Rep. Pregnant Rep. Pregnant Re. Pregnant Age No. % Age No. % Age No. % Age No. % Tharparkar/Mithi 7 205 12 5.9 74 5 6.8 75 1 1.3 354 18 5.1 Khairpur 7 420 27 6.4 160 16 10.0 130 2 1.5 710 45 6.3 Thatta 7 260 25 9.6 111 14 12.6 80 2 2.5 451 41 9.1 Dadu 7 282 11 3.9 146 10 6.8 89 1 1.1 517 22 4.3 Tando Allah Yar 10 223 21 9.4 87 2 2.3 70 0 0.0 380 23 6.1 Mirpurkhas 10 238 10 4.2 140 17 12.1 93 1 1.1 471 28 5.9 Zhob/Sheran 7 190 12 6.3 141 43 30.5 68 1 1.5 399 56 14.0 Noushki 7 268 26 9.7 65 22 33.8 61 5 8.2 394 53 13.5 Gawadar 7 181 38 21.0 70 19 27.1 40 5 12.5 291 62 21.3 Kech 7 243 25 10.3 92 11 12.0 65 3 4.6 400 39 9.8 Sibi/Harnai 7 283 10 3.5 115 8 7.0 85 2 2.4 483 20 4.1 Kila Saifullah 7 172 11 6.4 106 8 7.5 35 2 5.7 313 21 6.7 Nasirabad 7 143 25 17.5 121 20 16.5 36 1 2.8 300 46 15.3 Loralai 7 254 45 17.7 93 21 22.6 59 5 8.5 406 71 17.5 Mastung 7 226 17 7.5 97 21 21.6 54 3 5.6 377 41 10.9 Panjgur 10 282 39 13.8 112 17 15.2 69 5 7.2 463 61 13.2 Kharan 10 149 17 11.4 86 8 9.3 47 2 4.3 282 27 9.6 Chaghi 10 184 10 5.4 73 5 6.8 50 0 0.0 307 15 4.9 Washhuk 10 129 14 10.9 64 8 12.5 31 1 3.2 224 23 10.3 Pishin 10 159 6 3.8 124 6 4.8 48 0 0.0 331 12 3.6 Musakhel 10 164 10 6.1 69 1 1.4 77 2 2.6 310 13 4.2 Lakki Marwat 7 173 7 4.0 134 6 4.5 58 1 1.7 365 14 3.8 Bannu 7 362 8 2.2 185 5 2.7 108 0 0.0 655 13 2.0 Mardan 7 433 8 1.8 156 2 1.3 115 0 0.0 704 10 1.4 Tank 10 305 4 1.3 144 8 5.6 93 1 1.1 542 13 2.4 Charsada 10 424 27 6.4 145 10 6.9 123 0 0.0 692 37 5.3 Nowshera 10 337 12 3.6 158 6 3.8 80 0 0.0 575 18 3.1 D.I.Khan 10 312 5 1.6 114 8 7.0 84 0 0.0 510 13 2.5 Kurram 7 194 28 14.4 132 11 8.3 55 2 3.6 381 41 10.8 Khyber 7 196 23 11.7 85 4 4.7 53 3 5.7 334 30 9.0 Bajaur 7 455 1 0.2 202 0 0.0 136 0 0.0 793 1 0.1 North Wazirastan 10 95 0 0.0 24 0 0.0 24 1 4.2 143 1 0.7 Orakzai 10 198 20 10.1 87 14 16.1 89 0 0.0 374 34 9.1 Mohmand 10 267 5 1.9 115 2 1.7 80 0 0.0 462 7 1.5 South Waziristan 10 215 0 0.0 137 0 0.0 72 0 0.0 424 0 0.0 FR Peshawar / Kohat 10 167 5 3.0 103 1 1.0 63 1 1.6 333 7 2.1 FR Bannu/Lakki 10 137 5 3.6 48 2 4.2 42 1 2.4 227 8 3.5 FR Tank/DI Khan 10 45 0 0.0 25 1 4.0 17 0 0.0 87 1 1.1 Total 8970 569 6.3 4140 362 8.7 2654 54 2.0 15764 985 6.2
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10.4. KNOWLEDGE, ATTITUDES AND PRACTICES ON MALARIA Table 66: Heard about Malaria and source of information (age 15 years & above) Health District Heard Personal about Elect. Media Print Media Facility LHW member malaria No. % No. % No. % No. % No. % Tharparkar/Mithi 886 51 5.8 2 0.2 720 81.3 130 14.7 73 8.2 Khairpur 1667 466 28.0 72 4.3 503 30.2 68 4.1 1358 81.5 Thatta 918 264 28.8 129 14.1 523 57.0 53 5.8 634 69.1 Dadu 1091 215 19.7 28 2.6 598 54.8 246 22.5 656 60.1 Tando Allah Yar 510 212 41.6 8 1.6 201 39.4 46 9.0 198 38.8 Mirpurkhas 547 150 27.4 31 5.7 327 59.8 35 6.4 147 26.9 Zhob/Sheran 974 123 12.6 224 23.0 379 38.9 78 8.0 616 63.2 Noushki 843 89 10.6 272 32.3 346 41.0 80 9.5 562 66.7 Gawadar 707 176 24.9 135 19.1 404 57.1 159 22.5 514 72.7 Kech 850 426 50.1 222 26.1 543 63.9 376 44.2 471 55.4 Sibi/Harnai 749 354 47.3 56 7.5 266 35.5 88 11.7 524 70.0 Kila Saifullah 777 419 53.9 335 43.1 518 66.7 246 31.7 652 83.9 Nasirabad 588 252 42.9 41 7.0 289 49.1 53 9.0 429 73.0 Loralai 972 155 15.9 173 17.8 358 36.8 114 11.7 932 95.9 Mastung 785 405 51.6 237 30.2 516 65.7 232 29.6 445 56.7 Panjgur 959 330 34.4 74 7.7 303 31.6 72 7.5 239 24.9 Kharan 375 18 4.8 6 1.6 198 52.8 7 1.9 271 72.3 Chaghi 654 52 8.0 35 5.4 594 90.8 21 3.2 67 10.2 Washhuk 359 34 9.5 0 0.0 269 74.9 21 5.8 101 28.1 Pishin 668 52 7.8 60 9.0 563 84.3 29 4.3 197 29.5 Musakhel 692 23 3.3 26 3.8 623 90.0 84 12.1 94 13.6 Lakki Marwat 468 133 28.4 142 30.3 131 28.0 24 5.1 277 59.2 Bannu 765 101 13.2 66 8.6 457 59.7 33 4.3 247 32.3 Mardan 968 164 16.9 28 2.9 141 14.6 65 6.7 379 39.2 Tank 465 95 20.4 58 12.5 180 38.7 3 0.6 280 60.2 Charsada 737 163 22.1 62 8.4 146 19.8 24 3.3 510 69.2 Nowshera 593 221 37.3 93 15.7 100 16.9 14 2.4 486 82.0 D.I.Khan 467 130 27.8 56 12.0 82 17.6 5 1.1 341 73.0 Kurram 412 26 6.3 40 9.7 355 86.2 148 35.9 35 8.5 Khyber 873 378 43.3 317 36.3 801 91.8 10 1.1 358 41.0 Bajaur 800 374 46.8 442 55.3 546 68.3 183 22.9 419 52.4 North Wazirastan 379 110 29.0 15 4.0 240 63.3 0 0.0 173 45.6 Orakzai 197 80 40.6 22 11.2 74 37.6 4 2.0 81 41.1 Mohmand 649 17 2.6 17 2.6 357 55.0 2 0.3 268 41.3 South Waziristan 635 6 0.9 3 0.5 396 62.4 0 0.0 278 43.8 FR Peshawar/Kohat 496 293 59.1 92 18.5 201 40.5 5 1.0 143 28.8 FR Bannu/Lakki 274 80 29.2 72 26.3 189 69.0 3 1.1 130 47.4 FR Tank/DI Khan 194 90 46.4 141 72.7 50 25.8 0 0.0 25 12.9 Total 25943 6727 25.9 3832 14.8 13487 52.0 2761 10.6 13610 52.5
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10.5. KNOWLEDGE ABOUT CAUSE, SYMPTOMS & LETHALITY OF MALARIA
Table 67: Percentage of people (15 years and above) who knew the cause, symptoms, lethality and prevention of malaria (38 GF Districts). (The proportion is out of 25943 individuals who heard about malaria).
Individuals said Malaria can Kill Malaria is Caused by Symptom -Fever if not treated Prevention Districts Mosquito No % No % No. % Tharparkar/Mithi 878 849 96.7 862 98.2 749 85.3 Khairpur 1657 1547 93.4 1632 98.5 1592 96.1 Thatta 868 590 68.0 784 90.3 803 92.5 Dadu 1077 1015 94.2 825 76.6 824 76.5 Tando Allah Yar 490 445 90.8 454 92.7 445 90.8 Mirpurkhas 544 499 91.7 503 92.5 485 89.2 Zhob/Sheran 948 720 75.9 582 61.4 867 91.5 Noushki 781 666 85.3 658 84.3 723 92.6 Gawadar 678 607 89.5 564 83.2 642 94.7 Kech 733 435 59.3 584 79.7 658 89.8 Sibi/Harnai 731 705 96.4 652 89.2 600 82.1 Kila Saifullah 774 756 97.7 744 96.1 752 97.2 Nasirabad 571 546 95.6 237 41.5 441 77.2 Loralai 950 848 89.3 392 41.3 622 65.5 Mastung 759 704 92.8 556 73.3 622 81.9 Panjgur 872 787 90.3 711 81.5 739 84.7 Kharan 362 354 97.8 243 67.1 258 71.3 Chaghi 648 646 99.7 432 66.7 595 91.8 Washhuk 353 313 88.7 326 92.4 322 91.2 Pishin 660 636 96.4 470 71.2 589 89.2 Musakhel 680 671 98.7 626 92.1 665 97.8 Lakki Marwat 419 388 92.6 291 69.5 302 72.1 Bannu 727 491 67.5 694 95.5 666 91.6 Mardan 729 639 87.7 305 41.8 533 73.1 Tank 421 391 92.9 367 87.2 333 79.1 Charsada 635 510 80.3 391 61.6 441 69.4 Nowshera 536 489 91.2 432 80.6 419 78.2 D.I.Khan 389 354 91.0 332 85.3 293 75.3 Kurram 411 409 99.5 277 67.4 348 84.7 Khyber 810 783 96.7 752 92.8 710 87.7 Bajaur 406 386 95.1 406 100.0 398 98.0 North Wazirastan 360 311 86.4 321 89.2 284 78.9 Orakzai 70 62 88.6 30 42.9 30 42.9 Mohmand 364 343 94.2 287 78.8 203 55.8 South Waziristan 601 562 93.5 477 79.4 548 91.2 FR Peshawar/Kohat 420 410 97.6 278 66.2 238 56.7 FR Bannu/Lakki 239 225 94.1 193 80.8 184 77.0 FR Tank/DI Khan 188 185 98.4 168 89.4 164 87.2 Total 23739 21277 89.6 18838 79.4 20087 84.6
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Table 68: Importance of Malaria by district Information available Malaria can kill if not treated
Age 15+ Yes % No % Don’t know % Individuals Tharparkar/Mithi 878 873 99.4 3 0.3 2 0.2 Khairpur 1665 1651 99.2 2 0.1 12 0.7 Thatta 1047 833 79.6 31 3.7 183 17.5 Dadu 1147 838 73.1 21 2.5 288 25.1 Tando Allah Yar 556 487 87.6 34 7.0 35 6.3 Mirpurkhas 547 504 92.1 41 8.1 2 0.4 Zhob/Sheran 976 593 60.8 83 14.0 300 30.7 Noushki 855 679 79.4 39 5.7 137 16.0 Gawadar 709 591 83.4 86 14.6 32 4.5 Kech 881 688 78.1 32 4.7 161 18.3 Sibi/Harnai 800 680 85.0 10 1.5 110 13.8 Kila Saifullah 773 746 96.5 4 0.5 23 3.0 Nasirabad 595 240 40.3 74 30.8 281 47.2 Loralai 989 397 40.1 204 51.4 388 39.2 Mastung 811 572 70.5 26 4.5 213 26.3 Panjgur 1102 830 75.3 1 0.1 271 24.6 Kharan 526 252 47.9 9 3.6 265 50.4 Chaghi 707 439 62.1 132 30.1 136 19.2 Washhuk 449 334 74.4 18 5.4 97 21.6 Pishin 664 480 72.3 25 5.2 159 23.9 Musakhel 693 633 91.3 5 0.8 55 7.9 Lakki Marwat 549 315 57.4 24 7.6 210 38.3 Bannu 808 725 89.7 6 0.8 77 9.5 Mardan 596 356 59.7 111 31.2 129 21.6 Tank 582 458 78.7 11 2.4 113 19.4 Charsada 828 479 57.9 83 17.3 266 32.1 Nowshera 669 470 70.3 19 4.0 180 26.9 D.I.Khan 512 430 84.0 12 2.8 70 13.7 Kurram 447 282 63.1 20 7.1 145 32.4 Khyber 906 801 88.4 3 0.4 102 11.3 Bajaur 683 682 99.9 0 0.0 1 0.1 North Waziristan 380 336 88.4 2 0.6 42 11.1 Orakzai 124 42 33.9 5 11.9 77 62.1 Mohmand 770 437 56.8 81 18.5 252 32.7 South Waziristan 684 505 73.8 104 20.6 75 11.0 FR Peshawar/Kohat 438 292 66.7 22 7.5 124 28.3 FR Bannu/Lakki 277 212 76.5 1 0.5 64 23.1 FR Tank/DI Khan 236 176 74.6 2 1.1 58 24.6 Total 26859 20338 75.7 1386 6.8 5135 19.1
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10.6. ATTITUDE AND PRACTICES FOR MALARIA PREVENTION
Table 69: Treatment seeking behavior in cases suffering from fever at the time of survey by district
Seek treatment
District Fever Within 24 hours 48 hours 72 hours
No. % No. % No. %
Tando Allah Yar 40 19 47.5 21 52.5 0 0.0
Mirpurkhas 45 16 35.6 28 62.2 1 2.2
Panjgur 67 21 31.3 46 68.7 0 0.0
Kharan 14 8 57.1 5 35.7 1 7.1
Chaghi 37 20 54.1 17 45.9 0 0.0
Washhuk 24 17 70.8 7 29.2 0 0.0
Pishin 20 10 50.0 10 50.0 0 0.0
Musakhel 91 47 51.6 44 48.4 0 0.0
Tank 29 27 93.1 2 6.9 0 0.0
Charsada 22 11 50.0 10 45.5 1 4.5
Nowshera 10 9 90.0 1 10.0 0 0.0
D.I.Khan 68 51 75.0 12 17.6 5 7.4
North Wazirastan 39 29 74.4 10 25.6 0 0.0
Orakzai 33 32 97.0 1 3.0 0 0.0
Mohmand 77 59 76.6 18 23.4 0 0.0
South Waziristan 6 2 33.3 4 66.7 0 0.0
FR Peshawar/Kohat 34 34 100.0 0 0.0 0 0.0
FR Bannu/Lakki 44 37 84.1 7 15.9 0 0.0
FR Tank/DI Khan 17 17 100.0 0 0.0 0 0.0
Total 717 466 65.0 243 33.9 8 1.1
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Table 70: Treatment-Seeking behavior in those who ever had fever (38 districts)
Fever in the Seek Within 24 House 48 hours Round last 72 hrs treatment hrs 72 hours hold Yes % No. % No. % No. % No. % Tharparkar / Mithi 7 248 13 5.2 12 5 5 41.7 1 8.3 6 50.0 Khairpur 7 395 154 41.5 151 89.3 144 95.4 6 4.0 1 0.7 Thatta 7 345 69 20 64 28.2 38 59.4 22 34.4 4 6.3 Dadu 7 385 92 23.9 74 58.3 55 74.3 16 21.6 3 4.1 Tando Allah Yar 10 281 50 6.8 41 87.2 21 51.2 15 36.6 5 12.2 Mirpurkhas 10 393 53 5.9 45 84.9 16 35.6 25 55.6 4 8.9 Zhob/Sheran 7 246 44 17.9 19 73.1 17 89.5 2 10.5 0 0.0 Noushki 7 195 47 54.9 21 61.8 14 66.7 6 28.6 1 4.8 Gawadar 7 247 45 17.4 43 29.9 30 69.8 12 27.9 1 2.3 Kech 7 299 105 11.7 96 89.7 40 41.7 38 39.6 18 18.8 Sibi/Harnai 7 235 79 50.6 36 73.5 19 52.8 14 38.9 3 8.3 Kila Saifullah 7 248 49 19.8 37 44 34 91.9 3 8.1 0 0.0 Nasirabad 7 247 130 12.1 105 82 63 60.0 40 38.1 2 1.9 Loralai 7 217 43 19.8 36 70.6 23 63.9 11 30.6 2 5.6 Mastung 7 236 68 28.8 24 11.5 13 54.2 8 33.3 3 12.5 Panjgur 10 293 31 10.6 9 90 5 55.6 1 11.1 3 33.3 Kharan 10 184 62 33.7 7 87.5 2 28.6 3 42.9 2 28.6 Chaghi 10 247 93 37.7 22 73.3 11 50.0 8 36.4 3 13.6 Washhuk 10 181 49 27.1 25 89.3 16 64.0 7 28.0 2 8.0 Pishin 10 290 45 15.5 41 89.1 24 58.5 16 39.0 1 2.4 Musakhel 10 242 64 18.2 54 94.7 20 37.0 27 50.0 7 13.0 Lakki Marwat 7 295 40 3.4 37 75.5 23 62.2 11 29.7 3 8.1 Bannu 7 344 58 2.3 50 67.6 31 62.0 14 28.0 5 10.0 Mardan 7 361 30 8.3 29 13.2 19 65.5 4 13.8 6 20.7 Tank 10 281 28 8.2 25 58.1 24 96.0 1 4.0 0 0.0 Charsada 10 369 68 7 65 76.5 37 56.9 18 27.7 10 15.4 Nowshera 10 379 57 15 17 89.5 8 47.1 5 29.4 4 23.5 D.I.Khan 10 324 43 13.3 33 52.4 10 30.3 16 48.5 7 21.2 Kurram 7 297 85 28.6 58 28.9 55 94.8 3 5.2 0 0.0 Khyber 7 296 99 6.4 90 91.8 26 28.9 48 53.3 16 17.8 Bajaur 7 297 63 21.2 36 14.3 22 61.1 13 36.1 1 2.8 North Wazirastan 10 237 72 26.2 69 88.5 64 92.8 5 7.2 0 0.0 Orakzai 10 242 64 12.8 54 88.5 22 40.7 32 59.3 0 0.0 Mohmand 10 298 76 25.5 51 67.1 28 54.9 14 27.5 9 17.6 South Waziristan 10 296 71 17.2 66 85.7 34 51.5 32 48.5 0 0.0 FR Peshawar / 10 247 104 25.9 92 97.9 61 66.3 31 33.7 0 0.0 Kohat FR Bannu / Lakki 10 143 48 28.7 43 89.6 28 65.1 11 25.6 4 9.3 FR Tank / DI Khan 10 199 144 72.4 143 95.3 142 99.3 1 0.7 0 0.0 Total 10559 2535 72.4 1920.0 95.3 1244 64.8 540 28.1 136 7.1
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Table 71: Self treatment of Malaria in 38 districts
Self Home Allopathic Homeopath Round House treatment Remedies hold No. % No. % No. % .No. % Tharparkar/Mithi 7 248 8 3.2 8 100.0 0 0.0 0 0.0 Khairpur 7 395 133 33.7 133 100.0 0 0.0 0 0.0 Thatta 7 345 173 50.1 53 30.6 52 30.1 68 39.3 Dadu 7 385 27 7.0 22 81.5 0 0.0 5 18.5 Tando Allah Yar 10 281 81 28.8 57 70.4 18 22.2 6 7.4 Mirpurkhas 10 393 99 25.2 91 91.9 6 6.1 2 2.0 Zhob/Sheran 7 246 71 28.9 43 60.6 1 1.4 27 38.0 Noushki 7 195 55 28.2 40 72.7 3 5.5 12 21.8 Gawadar 7 247 19 7.7 17 89.5 2 10.5 0 0.0 Kech 7 299 63 21.1 47 74.6 4 6.3 12 19.0 Sibi/Harnai 7 235 83 35.3 69 83.1 5 6.0 9 10.8 Kila Saifullah 7 248 43 17.3 42 97.7 0 0.0 1 2.3 Nasirabad 7 247 49 19.8 46 93.9 0 0.0 3 6.1 Loralai 7 217 18 8.3 17 94.4 1 5.6 0 0.0 Mastung 7 236 43 18.2 27 62.8 8 18.6 8 18.6 Panjgur 10 293 9 3.1 0 0.0 0 0.0 9 100.0 Kharan 10 184 14 7.6 8 57.1 1 7.1 5 35.7 Chaghi 10 247 71 28.7 47 66.2 1 1.4 23 32.4 Washhuk 10 181 2 1.1 1 50.0 1 50.0 0 0.0 Pishin 10 290 46 15.9 44 95.7 0 0.0 2 4.3 Musakhel 10 242 20 8.3 19 95.0 1 5.0 0 0.0 Lakki Marwat 7 295 60 20.3 56 93.3 4 6.7 0 0.0 Bannu 7 344 39 11.3 34 87.2 2 5.1 3 7.7 Mardan 7 361 238 65.9 94 39.5 144 60.5 0 0.0 Tank 10 281 78 27.8 75 96.2 1 1.3 2 2.6 Charsada 10 369 157 42.5 156 99.4 1 0.6 0 0.0 Nowshera 10 379 93 24.5 90 96.8 3 3.2 0 0.0 D.I.Khan 10 324 96 29.6 91 94.8 1 1.0 4 4.2 Kurram 7 297 128 43.1 128 100.0 0 0.0 0 0.0 Khyber 7 296 99 33.4 92 92.9 6 6.1 1 1.0 Bajaur 7 297 296 99.7 295 99.7 1 0.3 0 0.0 North Wazirastan 10 237 18 7.6 17 94.4 1 5.6 0 0.0 Orakzai 10 242 214 88.4 112 52.3 102 47.7 0 0.0 Mohmand 10 298 20 6.7 17 85.0 3 15.0 0 0.0 South Waziristan 10 296 92 31.1 89 96.7 2 2.2 1 1.1 FR Peshawar/Kohat 10 247 58 23.5 8 13.8 50 86.2 0 0.0 FR Bannu/Lakki 10 143 13 9.1 13 100.0 0 0.0 0 0.0 FR Tank/DI Khan 10 199 130 65.3 130 100.0 0 0.0 0 0.0 Total 10559 2956 28 2328 78.8 425 14.4 203 6.9
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Table 72: Preference for using public or private facility and the type of health care provider for fever
Places generally prefer for treatment of fever House- District Round Priv. Manage Home- Spirit. Med. Hold Govt. LHW Hakim Other Pract at home opath Healer Store Tharparkar / Mithi 7 250 73 175 0 1 0 0 1 0 0 Khairpur 7 400 87 298 0 0 5 3 6 1 0 Thatta 7 349 149 199 0 0 0 0 0 0 1 Dadu 7 391 165 210 2 2 1 0 9 2 0 Tando Allah Yar 10 294 144 143 7 0 0 0 0 0 0 Mirpurkhas 10 397 177 216 3 0 0 0 1 0 0 Zhob / Sheran 7 249 160 56 3 2 1 2 25 0 0 Noushki 7 200 116 68 8 1 1 0 6 0 0 Gawadar 7 249 191 54 1 1 1 1 0 0 0 Kech 7 300 187 90 4 4 4 1 2 8 0 Sibi / Harnai 7 250 43 178 6 0 1 6 15 1 0 Kila Saifullah 7 248 237 1 8 0 0 0 0 2 0 Nasirabad 7 249 100 145 2 1 0 0 1 0 0 Loralai 7 234 25 101 9 0 0 1 62 36 0 Mastung 7 241 172 49 6 4 1 2 3 4 0 Panjgur 10 300 234 57 1 7 1 0 0 0 0 Kharan 10 220 127 89 0 4 0 0 0 0 0 Chaghi 10 250 196 40 3 1 0 0 10 0 0 Washhuk 10 188 176 11 1 0 0 0 0 0 0 Pishin 10 300 111 179 4 0 0 0 4 2 0 Musakhel 10 250 95 120 2 1 1 0 31 0 0 Lakki Marwat 7 300 57 184 2 2 2 2 33 18 0 Bannu 7 349 108 236 3 0 1 0 1 0 0 Mardan 7 400 67 181 136 0 1 0 12 1 2 Tank 10 299 193 0 21 22 11 10 23 18 1 Charsada 10 399 176 94 3 1 2 1 26 74 22 Nowshera 10 403 180 132 8 3 0 0 16 63 1 D.I.Khan 10 350 136 103 13 12 10 6 39 31 0 Kurram 7 300 290 0 0 0 0 0 10 0 0 Khyber 7 300 226 54 1 0 1 0 1 17 0 Bajaur 7 300 186 6 82 0 0 0 3 4 19 North Wazirastan 10 247 199 0 2 0 0 0 24 22 0 Orakzai 10 249 116 62 58 0 1 0 1 0 11 Mohmand 10 300 84 215 1 0 0 0 0 0 0 South Waziristan 10 300 149 129 2 0 1 2 15 0 2 FR Peshawar / 10 249 149 100 0 Kohat 0 0 0 0 0 0 FR Bannu / Lakki 10 150 40 110 0 0 0 0 0 0 0 FR Tank / DI Khan 10 200 191 9 0 0 0 0 0 0 0 Total No. 10904 5512 4094 402 69 47 37 380 304 59 % age 50.6 37.5 3.7 0.6 0.4 0.3 3.5 2.8 0.5
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Table 73: Reasons for not using Government Health Facilities
Not using Govt. Multiple Reasons for not using Govt. health facility House Health facility hold No For Difficult Dissat Staff Staff NA
Round No. % Other H.F away Access isfied NA Behav. Med. Tharparkar / Mithi 7 250 177 70.8 12 8 12 10 1 1 139 0 Khairpur 7 400 313 78.3 39 9 14 81 20 106 184 3 Thatta 7 349 200 57.3 66 39 54 65 34 29 61 1 Dadu 7 391 226 57.8 23 12 3 166 25 28 82 1 Tando Allah Yar 10 294 150 51.0 3 24 10 98 6 18 10 2 Mirpurkhas 10 397 220 55.4 0 14 11 149 18 28 27 1 Zhob / Sheran 7 249 89 35.7 3 2 7 42 28 4 25 0 Noushki 7 200 84 42.0 5 1 1 43 11 17 28 0 Gawadar 7 249 58 23.3 10 24 12 12 2 3 14 0 Kech 7 300 113 37.7 13 10 16 38 45 3 17 0 Sibi / Harnai 7 250 207 82.8 5 4 4 67 54 23 163 5 Kila Saifullah 7 248 11 4.4 3 1 0 33 1 2 52 0 Nasirabad 7 249 149 59.8 1 12 1 75 19 19 124 0 Loralai 7 234 209 89.3 95 42 4 40 35 12 66 1 Mastung 7 241 69 28.6 0 0 3 30 7 14 40 1 Panjgur 10 300 66 22.0 0 11 2 3 8 0 18 5 Kharan 10 220 93 42.3 0 1 0 37 4 6 23 0 Chaghi 10 250 54 21.6 2 0 0 1 4 0 40 0 Washhuk 10 188 12 6.4 0 0 0 0 0 0 0 0 Pishin 10 300 189 63.0 2 1 0 96 20 7 96 1 Musakhel 10 250 155 62.0 0 11 0 80 19 3 84 2 Lakki Marwat 7 300 243 81.0 88 156 134 161 96 74 147 4 Bannu 7 349 241 69.1 7 40 20 147 20 11 108 1 Mardan 7 400 333 83.3 6 51 96 194 71 32 126 78 Tank 10 299 106 35.5 5 39 10 56 55 56 57 3 Charsada 10 399 223 55.9 28 62 20 57 19 0 39 2 Nowshera 10 403 223 55.3 27 82 24 151 78 66 97 5 D.I.Khan 10 350 214 61.1 23 86 18 81 64 58 88 2 Kurram 7 300 10 3.3 9 0 0 5 2 4 1 2 Khyber 7 300 74 24.7 3 29 0 20 0 0 1 7 Bajaur 7 300 114 38.0 0 0 20 24 2 0 1 1 North Wazirastan 10 247 48 19.4 1 1 4 30 5 0 8 2 Orakzai 10 249 133 53.4 0 2 21 16 1 0 2 0 Mohmand 10 300 216 72.0 0 0 5 182 82 12 129 11 South Waziristan 10 300 151 50.3 4 105 60 30 53 9 52 0 FR Peshawar / 10 249 100 40.2 0 2 3 12 2 0 37 1 Kohat FR Bannu / Lakki 10 150 110 73.3 0 0 1 55 10 1 96 0 FR Tank / DI Khan 10 200 9 4.5 1 0 0 2 0 0 0 0 Total 10904 5392 49.4 514 881 590 2399 921 646 2282 142 9.5 16.3 10.9 44.5 17.1 12.0 42.3 2.6
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Table 74: Distance of Government Health Facilities from the place of residence of the surveyed households by district Distance of health facility House- Districts Round Govt. % from home hold < 5 km 5-10 km > 10 km Tharparkar/Mithi 7 250 73 29.2 3 26 44 Khairpur 7 400 87 21.8 81 4 2 Thatta 7 349 149 42.7 77 34 38 Dadu 7 391 165 42.2 90 67 8 Tando Allah Yar 10 294 144 49.0 106 28 10 Mirpurkhas 10 397 177 44.6 131 46 0 Zhob/Sheran 7 249 160 64.3 146 0 14 Noushki 7 200 116 58.0 89 27 0 Gawadar 7 249 191 76.7 170 20 1 Kech 7 300 187 62.3 103 68 16 Sibi/Harnai 7 250 43 17.2 35 8 0 Kila Saifullah 7 248 237 95.6 234 3 0 Nasirabad 7 249 100 40.2 51 49 0 Loralai 7 234 25 10.7 18 7 0 Mastung 7 241 172 71.4 170 1 1 Panjgur 10 300 234 78.0 136 60 38 Kharan 10 220 127 57.7 127 0 0 Chaghi 10 250 196 78.4 183 1 12 Washhuk 10 188 176 93.6 175 1 0 Pishin 10 300 111 37.0 101 9 1 Musakhel 10 250 95 38.0 95 0 0 Lakki Marwat 7 300 57 19.0 21 33 3 Bannu 7 349 108 30.9 102 5 1 Mardan 7 400 67 16.8 60 6 1 Tank 10 299 193 64.5 189 1 3 Charsada 10 399 176 44.1 102 72 2 Nowshera 10 403 180 44.7 168 11 1 D.I.Khan 10 350 136 38.9 109 21 6 Kurram 7 300 290 96.7 239 0 51 Khyber 7 300 226 75.3 206 20 0 Bajaur 7 300 186 62.0 186 0 0 North Wazirastan 10 247 199 80.6 171 10 18 Orakzai 10 249 116 46.6 116 0 0 Mohmand 10 300 84 28.0 80 1 3 South Waziristan 10 300 149 49.7 56 83 10 FR Peshawar/Kohat 10 249 149 59.8 138 11 0 FR Bannu/Lakki 10 150 40 26.7 38 1 1 FR Tank/DI Khan 10 200 191 95.5 156 34 1 Total 10904 5512 50.6 4458 768 286 80.9 13.9 5.2
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Table 75: Health facility access: Round trip cost (Rupees) incurred by the households Pay for transport (Round trip) in rupees Inform. District Govt. < 100 101-500 501-1000 >1000 Available No. % No. % No. % No. % 100. Tharparkar/Mithi 73 73 73 0 0.0 0 0.0 0 0.0 0 Khairpur 87 21 11 52.4 9 42.9 1 4.8 0 0.0 Thatta 149 121 10 8.3 67 55.4 38 31.4 6 5.0 Dadu 165 134 93 69.4 41 30.6 0 0.0 0 0.0 Tando Allah Yar 144 70 39 55.7 25 35.7 6 8.6 0 0.0 Mirpurkhas 177 113 90 79.6 17 15.0 5 4.4 1 0.9 Zhob/Sheran 160 38 0 0.0 38 100.0 0 0.0 0 0.0 Noushki 116 71 47 66.2 24 33.8 0 0.0 0 0.0 Gawadar 191 94 67 71.3 26 27.7 0 0.0 1 1.1 Kech 187 110 4 3.6 53 48.2 26 23.6 27 24.5 Sibi/Harnai 43 17 1 5.9 16 94.1 0 0.0 0 0.0 Kila Saifullah 237 120 92 76.7 28 23.3 0 0.0 0 0.0 Nasirabad 100 98 66 67.3 31 31.6 1 1.0 0 0.0 Loralai 25 18 4 22.2 13 72.2 0 0.0 1 5.6 Mastung 172 92 21 22.8 40 43.5 31 33.7 0 0.0 Panjgur 234 191 0 0.0 69 36.1 92 48.2 30 15.7 Kharan 127 36 7 19.4 29 80.6 0 0.0 0 0.0 Chaghi 196 38 6 15.8 4 10.5 10 26.3 18 47.4 Washhuk 176 0 0 0.0 0 0.0 0 0 0 00 Pishin 111 73 2 2.7 61 83.6 6 8.2 4 5.5 Musakhel 95 20 0 0.0 8 40.0 8 40.0 4 20.0 Lakki Marwat 57 43 2 4.7 18 41.9 13 30.2 10 23.3 Bannu 108 67 31 46.3 34 50.7 1 1.5 1 1.5 Mardan 67 53 24 45.3 27 50.9 1 1.9 1 1.9 Tank 193 105 96 91.4 8 7.6 1 1.0 0 0.0 Charsada 176 146 29 19.9 95 65.1 22 15.1 0 0.0 Nowshera 180 121 20 16.5 100 82.6 0 0.0 1 0.8 D.I.Khan 136 112 79 70.5 30 26.8 2 1.8 1 0.9 Kurram 290 58 1 1.7 56 96.6 1 1.7 0 0.0 Khyber 226 96 4 4.2 92 95.8 0 0.0 0 0.0 Bajaur 186 50 2 4.0 48 96.0 0 0.0 0 0.0 North Wazirastan 199 143 9 6.3 134 93.7 0 0.0 0 0.0 Orakzai 116 46 45 97.8 1 2.2 0 0.0 0 0.0 Mohmand 84 16 10 62.5 3 18.8 3 18.8 0 0.0 South Waziristan 149 142 4 2.8 119 83.8 19 13.4 0 0.0 FR Peshawar/Kohat 149 41 7 17.1 34 82.9 0 0.0 0 0.0 FR Bannu/Lakki 40 3 1 33.3 0 0.0 1 33.3 1 33.3 FR Tank/DI Khan 191 192 103 53.6 89 46.4 0 0.0 0 0.0
Total 5512 2982 1100 36.9 1487 49.9 288 9.7 107 3.6
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Table 76: Time taken to access the health care provider
Hous- Times takes for a health care provider Districts Round Govt. Hold <1 hour % >1 hour % Tharparkar/Mithi 7 250 73 73 100.0 0 0.0 Khairpur 7 400 87 76 87.4 11 12.6 Thatta 7 349 149 30 20.1 119 79.9 Dadu 7 391 165 128 77.6 37 22.4 Tando Allah Yar 10 294 144 102 70.8 42 29.2 Mirpurkhas 10 397 177 153 86.4 24 13.6 Zhob/Sheran 7 249 160 146 91.3 14 8.8 Noushki 7 200 116 38 32.8 78 67.2 Gawadar 7 249 191 127 66.5 64 33.5 Kech 7 300 187 88 47.1 99 52.9 Sibi/Harnai 7 250 43 35 81.4 8 18.6 Kila Saifullah 7 248 237 235 99.2 2 0.8 Nasirabad 7 249 100 17 17.0 83 83.0 Loralai 7 234 25 13 52.0 12 48.0 Mastung 7 241 172 140 81.4 32 18.6 Panjgur 10 300 234 36 15.4 198 84.6 Kharan 10 220 127 123 96.9 4 3.1 Chaghi 10 250 196 187 95.4 9 4.6 Washhuk 10 188 176 157 89.2 19 10.8 Pishin 10 300 111 75 67.6 36 32.4 Musakhel 10 250 95 81 85.3 14 14.7 Lakki Marwat 7 300 57 35 61.4 22 38.6 Bannu 7 349 108 99 91.7 9 8.3 Mardan 7 400 67 55 82.1 12 17.9 Tank 10 299 193 182 94.3 11 5.7 Charsada 10 399 176 106 60.2 70 39.8 Nowshera 10 403 180 148 82.2 32 17.8 D.I.Khan 10 350 136 129 94.9 7 5.1 Kurram 7 300 290 281 96.9 9 3.1 Khyber 7 300 226 190 84.1 36 15.9 Bajaur 7 300 186 184 98.9 2 1.1 North Wazirastan 10 247 199 145 72.9 54 27.1 Orakzai 10 249 116 103 88.8 13 11.2 Mohmand 10 300 84 81 96.4 3 3.6 South Waziristan 10 300 149 96 64.4 53 35.6 FR Peshawar/Kohat 10 249 149 143 96.0 6 4.0 FR Bannu/Lakki 10 150 40 39 97.5 1 2.5 FR Tank/DI Khan 10 200 191 187 97.9 4 2.1 Total 10904 5512 4263 77.3 1249 22.7
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10.7. COVERAGE OF MALARIA PRVENTION INTERVENTIONS
10.7.1. Indoor Residual Spraying Coverage Table 77: Households sprayed using IRS in the last 12 months in 38 districts
House Sprayed Sprayed by whom Districts Round hold Yes % Gov % Private % D.K % Tharparkar/Mithi 7 250 3 1.2 0 0.0 2 66.7 1 33.3 Khairpur 7 400 54 13.5 51 94.4 2 3.7 1 1.9 Thatta 7 349 51 14.6 50 98.0 0 0.0 1 2.0 Dadu 7 391 24 6.1 23 95.8 0 0.0 1 4.2 Tando Allah Yar 10 294 86 29.3 79 91.9 3 3.5 4 4.7 Mirpurkhas 10 397 60 15.1 50 83.3 3 5.0 7 11.7 Zohb/Sheran 7 249 66 26.5 50 75.8 16 24.2 0 0.0 Noushki 7 200 24 12.0 0 0.0 23 95.8 1 4.2 Gawadar 7 249 41 16.5 38 92.7 3 7.3 0 0.0 Kech 7 300 13 4.3 12 92.3 1 7.7 0 0.0 Sibi/Harnai 7 250 5 2.0 1 20.0 4 80.0 0 0.0 Kila Saifullah 7 248 2 0.8 0 0.0 1 50.0 1 50.0 Nasirabad 7 249 12 4.8 4 33.3 8 66.7 0 0.0 Loralai 7 234 1 0.4 1 100.0 0 0.0 0 100.0 Mastung 7 241 11 4.6 0 0.0 10 90.9 1 9.1 Pamjgur 10 300 9 3.0 9 100.0 0 0.0 0 0.0 Kharan 10 220 20 9.1 0 0.0 20 100.0 0 0.0 Chaghi 10 250 1 0.4 0 0.0 0 0.0 1 100.0 Washhuk 10 188 40 21.3 0 0.0 39 97.5 1 2.5 Pishin 10 300 2 0.7 0 0.0 2 100.0 0 0.0 Musakhel 10 250 16 6.4 0 0.0 14 87.5 2 12.5 Lakki Marwat 7 300 56 18.7 53 94.6 3 5.4 0 0.0 Bannu 7 349 23 6.6 0 0.0 19 82.6 4 17.4 Mardan 7 400 4 1.0 4 100.0 0 0.0 0 0.0 Tank 10 299 47 15.7 33 70.2 14 29.8 0 0.0 Charsada 10 399 15 3.8 1 6.7 14 93.3 0 0.0 Nowshera 10 403 38 9.4 23 60.5 13 34.2 2 5.3 D.I.Khan 10 350 12 3.4 0 0.0 12 100.0 0 0.0 Kurram 7 300 117 39.0 112 95.7 4 3.4 1 0.9 Khyber 7 300 43 14.3 18 41.9 25 58.1 0 0.0 Bajaur 7 300 49 16.3 45 91.8 1 2.0 3 6.1 North Wazirastan 10 247 106 42.9 78 73.6 27 25.5 1 0.9 Orakzai 10 249 2 0.8 0 0.0 2 100.0 0 50.0 Mohmand 10 300 15 5.0 5 33.3 7 46.7 3 20.0 South Waziristan 10 300 61 20.3 1 1.6 56 91.8 4 1.6 FR Peshawar/Kohat 10 249 49 19.7 0 0.0 49 100.0 0 0.0 FR Bannu/Lakki 10 150 5 3.3 0 0.0 5 100.0 0 0.0 FR Tank/DI Khan 10 200 1 0.5 0 0.0 0 500.0 1 0.0 Total 10904 1184 10.9 741 62.6 402 34.0 41 3.5
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10.8. LONG LASTING INSECTICIDE TREATED NETS CHARACTERISTICS & USAGE
10.8.1. Ownership, acquisition & source of LLINs Table 78: Households having at least one LLIN or any other mosquito net (38 districts)
Districts Round Household LLIN % Observed % Tharparkar/Mithi 7 250 2 0.8 2 100.0 Khairpur 7 400 39 9.8 39 100.0 Thatta 7 349 82 23.5 47 57.3 Dadu 7 391 93 23.8 84 90.3 Tando Allah Yar 10 294 143 48.6 123 86.0 Mirpurkhas 10 397 100 25.2 76 76.0 Zhob/Sheran 7 249 49 19.7 49 100.0 Noushki 7 200 75 37.5 67 89.3 Gawadar 7 249 56 22.5 45 80.4 Kech 7 300 144 48.0 137 95.1 Sibi/Harnai 7 250 74 29.6 62 83.8 Kila Saifullah 7 248 146 58.9 144 98.6 Nasirabad 7 249 54 21.7 48 88.9 Loralai 7 234 48 20.5 43 89.6 Mastung 7 241 173 71.8 164 94.8 Panjgur 10 300 71 23.7 25 35.2 Kharan 10 220 128 58.2 104 81.3 Chaghi 10 250 198 79.2 167 84.3 Washhuk 10 188 98 52.1 84 85.7 Pishin 10 300 3 1.0 1 33.3 Musakhel 10 250 90 36.0 79 87.8 Lakki Marwat 7 300 38 12.7 23 60.5 Bannu 7 349 30 8.6 14 46.7 Mardan 7 400 84 21.0 30 35.7 Tank 10 299 133 44.5 62 46.6 Charsada 10 399 59 14.8 28 47.5 Nowshera 10 403 15 3.7 6 40.0 D.I.Khan 10 350 17 4.9 2 11.8 Kurram 7 300 240 80.0 133 55.4 Khyber 7 300 276 92.0 262 94.9 Bajaur 7 300 122 40.7 57 46.7 North Wazirastan 10 247 167 67.6 56 33.5 Orakzai 10 249 62 24.9 58 93.5 Mohmand 10 300 104 34.7 71 68.3 South Waziristan 10 300 235 78.3 113 48.1 FR Peshawar/Kohat 10 249 61 24.5 57 93.4 FR Bannu/Lakki 10 150 64 42.7 46 71.9 FR Tank/DI Khan 10 200 121 60.5 116 95.9 Total 10904 3694 33.9 2724 73.7
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10.8.2. Source of LLINs received Table 79: Households with at least one LLIN in 38 districts and period when nets were received When did you get these nets Districts Round LLIN <1 yr % 1-3 yrs % DK % Tharparkar/Mithi 7 2 1 50.0 1 50.0 0 0.0 Khairpur 7 39 22 56.4 14 35.9 3 7.7 Thatta 7 82 40 48.8 32 39.0 10 12.2 Dadu 7 93 74 79.6 11 11.8 8 8.6 Tando Allah Yar 10 143 117 81.8 22 15.4 4 2.8 Mirpurkhas 10 100 84 84.0 15 15.0 1 1.0 Zhob/Sheran 7 49 47 95.9 0 0.0 2 4.1 Noushki 7 75 61 81.3 4 5.3 10 13.3 Gawadar 7 56 48 85.7 6 10.7 2 3.6 Kech 7 144 85 59.0 51 35.4 8 5.6 Sibi/Harnai 7 74 27 36.5 36 48.6 11 14.9 Kila Saifullah 7 146 128 87.7 7 4.8 11 7.5 Nasirabad 7 54 34 63.0 4 7.4 16 29.6 Loralai 7 48 44 91.7 3 6.3 1 2.1 Mastung 7 173 130 75.1 28 16.2 15 8.7 Panjgur 10 71 68 95.8 1 1.4 2 2.8 Kharan 10 128 100 78.1 23 18.0 5 3.9 Chaghi 10 198 188 94.9 1 0.5 9 4.5 Washhuk 10 98 94 95.9 0 0.0 4 4.1 Pishin 10 3 0 0.0 2 66.7 1 33.3 Musakhel 10 90 83 92.2 2 2.2 5 5.6 Lakki Marwat 7 38 16 42.1 16 42.1 6 15.8 Bannu 7 30 10 33.3 18 60.0 2 6.7 Mardan 7 84 72 85.7 8 9.5 4 4.8 Tank 10 133 111 83.5 14 10.5 8 6.0 Charsada 10 59 19 32.2 26 44.1 14 23.7 Nowshera 10 15 4 26.7 8 53.3 3 20.0 D.I.Khan 10 17 14 82.4 3 17.6 0 0.0 Kurram 7 240 214 89.2 10 4.2 16 6.7 Khyber 7 276 194 70.3 65 23.6 17 6.2 Bajaur 7 122 113 92.6 8 6.6 1 0.8 North Wazirastan 10 167 67 40.1 93 55.7 7 4.2 Orakzai 10 62 47 75.8 13 21.0 2 3.2 Mohmand 10 104 99 95.2 1 1.0 4 3.8 South Waziristan 10 235 194 82.6 26 11.1 15 6.4 FR 10 61 54 88.5 1 1.6 6 9.8 Peshawar/Kohat FR Bannu/Lakki 10 64 52 81.3 6 9.4 6 9.4 FR Tank/DI Khan 10 121 109 90.1 0 0.0 12 9.9 Total 3694 2864 77.5 579 20.5 251 8.8
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10.9. NET POSSESSION OTHER THEN LLIN Table 80: Proportion of net possession by households other than LLINs in 38 districts
Districts Round Household Other Nets % Tharparkar/Mithi 7 250 3 1.2 Khairpur 7 400 26 6.5 Thatta 7 349 89 25.5 Dadu 7 391 16 4.1 Tando Allah Yar 10 294 133 45.2 Mirpurkhas 10 397 266 67.0 Zhob/Sheran 7 249 4 1.6 Noushki 7 200 14 7.0 Gawadar 7 249 43 17.3 Kech 7 300 118 39.3 Sibi/Harnai 7 250 8 3.2 Kila Saifullah 7 248 115 46.4 Nasirabad 7 249 11 4.4 Loralai 7 234 151 64.5 Mastung 7 241 100 41.5 Panjgur 10 300 287 95.7 Kharan 10 220 67 30.5 Chaghi 10 250 45 18.0 Washhuk 10 188 54 28.7 Pishin 10 300 112 37.3 Musakhel 10 250 90 36.0 Lakki Marwat 7 300 2 0.7 Bannu 7 349 14 4.0 Mardan 7 400 14 3.5 Tank 10 299 24 8.0 Charsada 10 399 42 10.5 Nowshera 10 403 40 9.9 D.I.Khan 10 350 9 2.6 Kurram 7 300 144 48.0 Khyber 7 300 34 11.3 Bajaur 7 300 4 1.3 North Wazirastan 10 247 70 28.3 Orakzai 10 249 5 2.0 Mohmand 10 300 30 10.0 South Waziristan 10 300 139 46.3 FR Peshawar/Kohat 10 249 28 11.2 FR Bannu/Lakki 10 150 7 4.7 FR Tank/DI Khan 10 200 2 1.0 Total 10904 2360 21.6
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Table 81: Households with at least one LLIN in 38 districts and source of nets received Where did you get these nets Districts Round LLIN Govt. % NGO % Self % DK % Tharparkar/Mithi 7 2 1 50.0 1 50.0 0 0.0 0 0.0 Khairpur 7 39 31 79.5 0 0.0 8 20.5 0 0.0 Thatta 7 82 38 46.3 5 6.1 36 43.9 3 3.7 Dadu 7 93 79 84.9 7 7.5 0 0.0 7 7.5 Tando Allah Yar 10 143 126 88.1 6 4.2 8 5.6 3 2.1 Mirpurkhas 10 100 79 79.0 17 17.0 3 3.0 1 1.0 Zhob/Sheran 7 49 47 95.9 0 0.0 1 2.0 1 2.0 Noushki 7 75 59 78.7 8 10.7 6 8.0 2 2.7 Gawadar 7 56 32 57.1 18 32.1 3 5.4 3 5.4 Kech 7 144 11 7.6 130 90.3 2 1.4 1 0.7 Sibi/Harnai 7 74 71 95.9 1 1.4 1 1.4 1 1.4 Kila Saifullah 7 146 37 25.3 109 74.7 0 0.0 0 0.0 Nasirabad 7 54 43 79.6 6 11.1 2 3.7 3 5.6 Loralai 7 48 41 85.4 0 0.0 6 12.5 1 2.1 Mastung 7 173 140 80.9 2 1.2 23 13.3 8 4.6 Panjgur 10 71 69 97.2 0 0.0 0 0.0 2 2.8 Kharan 10 128 0 0.0 127 99.2 0 0.0 1 0.8 Chaghi 10 198 114 57.6 84 42.4 0 0.0 0 0.0 Washhuk 10 98 9 9.2 85 86.7 0 0.0 4 4.1 Pishin 10 3 2 66.7 0 0.0 0 0.0 1 33.3 Musakhel 10 90 1 1.1 89 98.9 0 0.0 0 0.0 Lakki Marwat 7 38 0 0.0 30 78.9 3 7.9 5 13.2 Bannu 7 30 9 30.0 1 3.3 20 66.7 0 0.0 Mardan 7 84 76 90.5 2 2.4 2 2.4 4 4.8 Tank 10 133 50 37.6 77 57.9 5 3.8 1 0.8 Charsada 10 59 20 33.9 13 22.0 24 40.7 2 3.4 Nowshera 10 15 1 6.7 0 0.0 11 73.3 3 20.0 D.I.Khan 10 17 14 82.4 1 5.9 1 5.9 1 5.9 Kurram 7 240 61 25.4 172 71.7 0 0.0 7 2.9 Khyber 7 276 140 50.7 98 35.5 9 3.3 29 10.5 Bajaur 7 122 78 63.9 36 29.5 1 0.8 7 5.7 North Wazirastan 10 167 27 16.2 1 0.6 139 83.2 0 0.0 Orakzai 10 62 48 77.4 12 19.4 0 0.0 2 3.2 Mohmand 10 104 96 92.3 1 1.0 2 1.9 5 4.8 South Waziristan 10 235 167 71.1 56 23.8 12 5.1 0 0.0 FR Peshawar/Kohat 10 61 4 6.6 53 86.9 4 6.6 0 0.0 FR Bannu/Lakki 10 64 26 40.6 36 56.3 1 1.6 1 1.6 FR Tank/DI Khan 10 121 15 12.4 103 85.1 1 0.8 2 1.7 Total 3694 1862 50.4 1387 37.5 334 9.0 111 3.0
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10.10. USAGE OF MOSQUITO NETS Table 82: Percentage of all persons who slept under LLINs the night preceding the survey House Household Slept Round hold with LLIN Individuals No. % Tharparkar/Mithi 7 250 2 12 3 25.0 Khairpur 7 400 39 312 86 27.6 Thatta 7 349 82 410 170 41.5 Dadu 7 391 93 558 160 28.7 Tando Allah Yar 10 294 143 761 283 37.2 Mirpurkhas 10 397 100 800 228 28.5 Zhob/Sheran 7 249 49 294 75 25.5 Noushki 7 200 75 295 175 59.3 Gawadar 7 249 56 282 81 28.7 Kech 7 300 144 1152 483 41.9 Sibi/Harnai 7 250 74 518 144 27.8 Kila Saifullah 7 248 146 876 548 62.6 Nasirabad 7 249 54 324 180 55.6 Loralai 7 234 48 384 240 62.5 Mastung 7 241 173 1038 460 44.3 Panjgur 10 300 71 444 229 51.6 Kharan 10 220 128 538 489 90.9 Chaghi 10 250 198 832 716 86.1 Washhuk 10 188 98 392 354 90.3 Pishin 10 300 3 10 0 0.0 Musakhel 10 250 90 328 305 93.0 Lakki Marwat 7 300 38 296 50 16.9 Bannu 7 349 30 330 31 9.4 Mardan 7 400 84 832 50 6.0 Tank 10 299 133 772 228 29.5 Charsada 10 399 59 559 89 15.9 Nowshera 10 403 15 114 12 10.5 D.I.Khan 10 350 17 119 20 16.8 Kurram 7 300 240 1709 515 30.1 Khyber 7 300 276 2038 437 21.4 Bajaur 7 300 122 1922 81 4.2 North Wazirastan 10 247 167 792 254 32.1 Orakzai 10 249 62 431 175 40.6 Mohmand 10 300 104 768 27 3.5 South Waziristan 10 300 235 1503 649 43.2 FR Peshawar/Kohat 10 249 61 357 74 20.7 FR Bannu/Lakki 10 150 64 419 45 10.7 FR Tank/DI Khan 10 200 121 507 212 41.8 Total 10904 3694 24028 8358 34.8 Out of 8358, child <5 = 1877, , Pregnant =290
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Table 83: Percentage of children under 5 years of age who slept under LLIN last night by districts Under 5 years Districts Round Household HH with LLIN No. Slept LLIN % Tharparkar/Mithi 7 250 2 156 0 0.0 Khairpur 7 400 39 397 31 7.8 Thatta 7 349 82 219 53 24.2 Dadu 7 391 93 317 56 17.7 Tando Allah Yar 10 294 143 200 0 0.0 Mirpurkhas 10 397 100 317 54 17.0 Zhob/Sheran 7 249 49 138 16 11.6 Noushki 7 200 75 138 41 29.7 Gawadar 7 249 56 155 15 9.7 Kech 7 300 144 197 90 45.7 Sibi/Harnai 7 250 74 210 48 22.9 Kila Saifullah 7 248 146 298 185 62.1 Nasirabad 7 249 54 258 61 23.6 Loralai 7 234 48 329 46 14.0 Mastung 7 241 173 166 94 56.6 Panjgur 10 300 71 176 22 12.5 Kharan 10 220 128 204 132 64.7 Chaghi 10 250 198 210 154 73.3 Washhuk 10 188 98 93 74 79.6 Pishin 10 300 3 152 0 0.0 Musakhel 10 250 90 237 59 24.9 Lakki Marwat 7 300 38 247 17 6.9 Bannu 7 349 30 334 5 1.5 Mardan 7 400 84 371 0 0.0 Tank 10 299 133 250 11 4.4 Charsada 10 399 59 343 41 12.0 Nowshera 10 403 15 342 8 2.3 D.I.Khan 10 350 17 294 1 0.3 Kurram 7 300 240 198 153 77.3 Khyber 7 300 276 235 213 90.6 Bajaur 7 300 122 331 5 1.5 North Wazirastan 10 247 167 208 33 15.9 Orakzai 10 249 62 241 41 17.0 Mohmand 10 300 104 361 10 2.8 South Waziristan 10 300 235 108 57 52.8 FR Peshawar/Kohat 10 249 61 162 34 21.0 FR Bannu/Lakki 10 150 64 144 17 11.8 FR Tank/DI Khan 10 200 121 116 0 0.0 Total 10904 3694 8852 1877 21.2
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10.10.1. Usage of LLINs by pregnant women Table 84: Percentage of pregnant women who slept under LLIN last night in 38 districts
Districts Round Household LLIN Pregnant Slept % Tharparkar/Mithi 7 250 2 23 0 0.0 Khairpur 7 400 39 47 6 12.8 Thatta 7 349 82 42 2 4.8 Dadu 7 391 93 22 2 9.1 Tando Allah Yar 10 294 143 23 7 30.4 Mirpurkhas 10 397 100 28 5 17.9 Zhob/Sheran 7 249 49 58 18 31.0 Noushki 7 200 75 55 18 32.7 Gawadar 7 249 56 66 6 9.1 Kech 7 300 144 39 19 48.7 Sibi/Harnai 7 250 74 24 10 41.7 Kila Saifullah 7 248 146 23 17 73.9 Nasirabad 7 249 54 49 11 22.4 Loralai 7 234 48 79 7 8.9 Mastung 7 241 173 42 26 61.9 Panjgur 10 300 71 61 4 6.6 Kharan 10 220 128 27 16 59.3 Chaghi 10 250 198 15 12 80.0 Washhuk 10 188 98 23 16 69.6 Pishin 10 300 3 12 3 25.0 Musakhel 10 250 90 13 1 7.7 Lakki Marwat 7 300 38 17 1 5.9 Bannu 7 349 30 13 0 0.0 Mardan 7 400 84 10 0 0.0 Tank 10 299 133 13 2 15.4 Charsada 10 399 59 37 2 5.4 Nowshera 10 403 15 18 1 5.6 D.I.Khan 10 350 17 13 9 69.2 Kurram 7 300 240 42 33 78.6 Khyber 7 300 276 31 22 71.0 Bajaur 7 300 122 1 1 100.0 North Wazirastan 10 247 167 1 0 0.0 Orakzai 10 249 62 34 2 5.9 Mohmand 10 300 104 7 4 57.1 South Waziristan 10 300 235 0 0 0.0 FR Peshawar/Kohat 10 249 61 7 2 28.6 FR Bannu/Lakki 10 150 64 8 4 50.0 FR Tank/DI Khan 10 200 121 1 1 100.0 Total 10904 3694 1024 290 28.3
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10.10.2. Net coverage in Global Fund supported UCs Table 85: Distribution of LLINs in Union Councils covered or not covered with Global fund support in 19 districts of Round-7
Malaria Distribution of LLINs House- Control None One LLIN Two LLIN > two LLIN Districts Hold Program No. % No. % No. % No. % Covered 100 98 98.0 1 1.0 0 0.0 1 1.0 Tharparkar/Mithi Not covered 100 99 99.0 1 1.0 0 0.0 0 0.0 Covered 50 33 66.0 11 22.0 4 8.0 2 4.0 Khairpur Not covered 350 328 93.7 15 4.3 6 1.7 1 0.3 Covered 149 100 67.1 38 25.5 11 7.4 0 0.0 Thatta Not covered 200 168 84.0 19 9.5 10 5.0 3 1.5 Covered 50 2 4.0 12 24.0 17 34.0 19 38.0 Zhob/Sheran Not covered 199 198 99.5 1 0.5 0 0.0 0 0.0 Covered 100 33 33.0 18 18.0 32 32.0 17 17.0 Noushki Not covered 100 91 91.0 4 4.0 3 3.0 2 2.0 Covered 100 72 72.0 18 18.0 7 7.0 3 3.0 Gawadar Not covered 149 122 81.9 19 12.8 6 4.0 2 1.3 Covered 150 81 54.0 36 24.0 28 18.7 5 3.3 Sibi/Harnai Not covered 100 95 95.0 4 4.0 1 1.0 0 0.0 Covered 100 38 38.0 13 13.0 45 45.0 4 4.0 Kila Saifullah Not covered 148 63 42.6 16 10.8 61 41.2 8 5.4 Covered 50 41 82.0 4 8.0 4 8.0 1 2.0 Nasirabad Not covered 199 153 76.9 20 10.1 24 12.1 2 1.0 Covered 98 94 95.9 2 2.0 2 2.0 0 0.0 Loralai Not covered 136 91 66.9 11 8.1 14 10.3 20 14.7 Covered 200 176 88.0 15 7.5 4 2.0 5 2.5 Lakki Marwat Not covered 100 87 87.0 11 11.0 1 1.0 1 1.0 Covered 200 25 12.5 53 26.5 93 46.5 29 14.5 Khyber Not covered 100 0 0.0 63 63.0 30 30.0 7 7.0 Covered 50 48 96.0 0 0.0 0 0.0 2 4.0 Bajaur Not covered 250 131 52.4 72 28.8 35 14.0 12 4.8 Covered 1397 841 60.2 221 15.8 247 17.7 88 6.3 Total Not covered 2131 1626 76.3 256 12.0 191 9.0 58 2.7 Note: Six districts were excluded, because the Global supported did not fall in the randomly selected union councils surveyed in these districts
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10.11. PARASITE PREVALENCE
10.11.1. Prevalence of malaria parasites Table 86: Persons tested for Malaria using microscopy by Districts
Tested Absent Refusal
District - Round 10 No. of subject No. % No. % No. %
Tando Allah Yar 1599 1226 76.7 113 7.1 260 16.3
Mirpurkhas 1999 1523 76.2 155 7.8 321 16.1 118 Panjgur 1879 585 31.1 107 5.7 63.2 7 Kharan 1030 852 82.7 100 9.7 78 7.6
Chaghi 1381 1018 73.7 35 2.5 328 23.8
Washhuk 790 682 86.3 17 2.2 91 11.5
Pishin 1287 1221 94.9 13 1.0 53 4.1
Musakhel 1469 752 51.2 158 10.8 559 38.1
Tank 2032 1631 80.3 165 8.1 236 11.6
Charsada 2856 2040 71.4 370 13.0 446 15.6
Nowshera 2288 1544 67.5 463 20.2 281 12.3
D.I.Khan 2961 2409 81.4 221 7.5 331 11.2
North Waziristan 1171 1033 88.2 92 7.9 46 3.9
Orakzai 1732 799 46.1 371 21.4 562 32.4
Mohmand 2214 1676 75.7 225 10.2 313 14.1
South Waziristan 1921 1261 65.6 358 18.6 302 15.7
FR Peshawar/Kohat 1459 1205 82.6 166 11.4 88 6.0
FR Bannu/Lakki 982 691 70.4 170 17.3 121 12.3 100. FR Tank/DI Khan 267 267 0 0.0 0 0.0 0 Total 31317 22415 71.6 3299 10.5 5603 17.9
126
Table 87: Prevalence of malaria (microscopy+ RDTs) and PV: PF ratio by districts
Per Per Per Districts Tested Positive % PV % PF % PV : PF 1000 1000 1000
Tando Allah Yar 1226 2 0.16 1.6 1 0.08 0.8 1 0.08 0.82 50 : 50
Mirpurkhas 1523 3 0.20 2.0 3 0.20 2.0 0 0.00 0.00 100 : 00
Panjgur 585 1 0.17 1.7 0 0.00 0.0 1 0.17 1.71 0 : 100
Kharan 1058 3 0.28 2.8 3 0.28 2.8 0 0.00 0.00 100 : 00
Chaghi 1018 8 0.79 7.9 8 0.79 7.9 0 0.00 0.00 100 : 00
Washhuk 682 11 1.61 16.1 11 1.61 16.1 0 0.00 0.00 100 : 00
Pishin 1221 1 0.08 0.8 1 0.08 0.8 0 0.00 0.00 100 : 00
Musakhel 752 36 4.79 47.9 14 1.86 18.6 20 2.66 26.60 41 : 59
Tank 1631 36 2.21 22.1 36 2.21 22.1 0 0.00 0.00 100 : 00
Charsada 2040 19 0.93 9.3 19 0.93 9.3 0 0.00 0.00 100 : 00
Nowshera 1544 18 1.17 11.7 17 1.10 11.0 1 0.06 0.65 95 : 05
D.I.Khan 1638 13 0.79 7.9 12 0.73 7.3 1 0.06 0.61 92 : 08
North Wazirastan 1033 95 9.20 92.0 88 8.52 85.2 7 0.68 6.78 93 : 07
Orakzai 799 5 0.63 6.3 5 0.63 6.3 0 0.00 0.00 100 : 00
Mohmand 1676 33 1.97 19.7 29 1.73 17.3 4 0.24 2.39 88 : 12
South Waziristan 1261 13 1.03 10.3 13 1.03 10.3 0 0.00 0.00 100 : 00
FR Peshawar / 1205 8 0.66 6.6 8 0.66 6.6 0 0.00 0.00 100 : 00 Kohat
FR Bannu / Lakki 691 21 3.04 30.4 21 3.04 30.4 0 0.00 0.00 100 : 00
FR Tank / DI 832 31 3.73 37.3 7 0.84 8.4 23 2.76 27.64 23 : 77 Khan
Total 22415 357 1.59 15.9 296 1.32 13.2 58 0.26 2.59 84 : 16
127
Table 88: Prevalence of Malaria (microscopy and / or RDTs) in 19 districts of Round 10 by gender
Total Male Female Districts (Round-10) Tested Positive % Tested Positive % Tested Positive %
Tando Allah Yar 1226 2 0.2 583 0 0.0 643 2 0.3
Mirpurkhas 1523 3 0.2 745 1 0.1 778 2 0.3
Panjgur 585 1 0.2 444 0 0.0 141 1 0.7
Kharan 1058 3 0.3 504 1 0.2 554 2 0.4
Chaghi 1018 8 0.8 519 7 1.3 499 1 0.2
Washhuk 682 11 1.6 325 6 1.8 357 5 1.4
Pishin 1221 1 0.1 596 1 0.2 625 0 0.0
Musakhel 752 36 4.8 402 15 3.7 350 21 6.0
Tank 1631 36 2.2 749 16 2.1 882 20 2.3
Charsada 2040 19 0.9 951 7 0.7 1089 12 1.1
Nowshera 1544 18 1.2 691 10 1.4 853 8 0.9
D.I.Khan 1638 13 0.8 749 4 0.5 889 9 1.0
North Wazirastan 1033 95 9.2 714 66 9.2 319 29 9.1
Orakzai 799 5 0.6 540 3 0.6 259 2 0.8
Mohmand 1676 33 2.0 750 14 1.9 926 19 2.1
South Waziristan 1261 13 1.0 893 12 1.3 368 1 0.3
FR Peshawar/Kohat 1205 8 0.7 673 4 0.6 532 4 0.8
FR Bannu/Lakki 691 21 3.0 320 9 2.8 371 12 3.2
FR Tank/DI Khan 832 31 3.7 586 14 2.4 246 17 6.9
Total 22415 357 1.6 11734 190 1.6 10681 167 1.6
128
Table 89: Prevalence of Malaria (microscopy and / or RDTs) in 19 districts of Round 10 by age
Total Under 5 yrs 5-14 yrs 15-49 yrs 50 * yrs Districts (Round-10) Tested +ve Tested +ve Tested +ve Tested +ve Tested +ve
Tando Allah Yar 1226 2 160 0 410 0 578 2 76 0
Mirpurkhas 1523 3 225 0 460 0 739 3 99 0
Panjgur 585 1 88 1 297 0 189 0 10 0
Kharan 1058 3 175 0 356 1 455 2 72 0
Chaghi 1018 8 188 3 367 5 417 0 46 0
Washhuk 682 11 75 0 191 2 377 8 39 1
Pishin 1221 1 150 0 407 0 587 1 77 0
Musakhel 752 36 115 7 234 16 329 13 74 0
Tank 1631 36 217 5 501 9 773 19 140 3
Charsada 2040 19 283 3 631 3 890 12 226 1
Nowshera 1544 18 271 1 442 12 660 4 168 1
D.I.Khan 1638 13 236 4 528 4 718 3 156 2 North 1033 95 163 13 345 37 481 39 44 6 Wazirastan Orakzai 799 5 100 1 161 1 444 2 94 1
Mohmand 1676 33 313 4 593 13 629 10 141 6 South 1261 13 90 0 390 3 706 8 75 2 Waziristan FR 1205 8 145 1 374 4 574 3 112 0 Peshawar/Kohat FR Bannu/Lakki 691 21 102 6 188 8 344 7 57 0 FR Tank/DI 832 31 116 3 344 13 314 13 58 2 Khan Total 22415 357 3212 52 7219 131 10204 149 1764 25 Age not known in 16 individuals
129
Table 90: Province and district wise estimated number of cases of malaria according to malaria prevalence
Overall Vivax Falciparum Districts Population Tested Positive % Estimated Positive % Estimated Positive % Estimated
Sindh 1737467 2749 5 0.18 3165 4 0.15 2532 1 0.04 633
Tando Allah 582393 1226 2 0.16 952 1 0.08 476 1 0.08 476 Yar Mirpurkhas 1155074 1523 3 0.20 2278 3 0.20 2278 0 0.00 0
Balochistan 1326495 5110 57 1.12 14987 34 0.67 9203 21 0.41 5522
Panjgur 284929 585 1 0.17 546 0 0.00 0 1 0.17 546
Kharan 116290 852 0 0.00 0 0.00 0 0 0.00 0
Chaghi 124778 1018 8 0.79 981 8 0.79 981 0 0.00 0
Washhuk 118430 682 11 1.61 1910 11 1.61 1910 0 0.00 0
Pishin 517712 1221 1 0.08 424 1 0.08 424 0 0.00 0
Musakhel 164356 752 36 4.79 7889 14 1.86 3287 20 2.66 4383
KPK 3982750 7624 116 1.52 60622 90 1.18 47034 25 0.33 13065
Tank 321778 1631 36 2.21 7102 36 2.21 7102 0 0.00 0
Charsada 1341349 2040 19 0.93 12505 19 0.93 12505 0 0.00 0
Nowshera 1149863 1544 18 1.17 13414 17 1.10 12669 1 0.06 745
D.I.Khan 1169760 2409 43 1.78 20880 18 0.75 8740 24 1.00 11654
FATA 1848679 6932 179 2.58 47778 168 2.42 44575 11 0.16 2936 North 400029 1033 95 9.20 36789 88 8.52 34078 7 0.68 2711 Waziristan Orakzai 258555 799 5 0.63 1632 5 0.63 1632 0 0.00 0
Mohmand 456403 1676 33 1.97 8986 29 1.73 7625 4 0.24 1089 South 448861 1261 13 1.03 4627 13 1.03 4627 0 0.00 0 Waziristan FR Peshawar/Ko 125404 1205 8 0.66 832 8 0.66 832 0 0.00 0 hat FR 55759 691 21 3.04 1695 21 3.04 1695 0 0.00 0 Bannu/Lakki FR Tank/DI 103668 267 4 1.50 1553 4 1.50 1553 0 0.00 0 Khan Total 8895391 22415 357 1.59 142170 296 1.32 117878 58 0.26 23098
Ratio of PV and PF (Mixed = 3 not include)
130
10.12. PREVALENCE OF FEVER AT THE TIME OF SURVEY Table 91: Prevalence of fever at the time of survey by gender in Roud-10 districts
Individuals Male Female Districts Household No. Fever % No. Fever % No. Fever %
Tando Allah Yar 294 1600 43 2.7 841 23 2.7 759 20 2.6
Mirpurkhas 397 1999 47 2.4 1048 24 2.3 951 23 2.4
Panjgur 300 1879 68 3.6 1084 41 3.8 795 27 3.4
Kharan 220 1324 13 1.0 694 6 0.9 630 7 1.1
Chaghi 250 1381 37 2.7 732 18 2.5 649 19 2.9
Washhuk 188 790 24 3.0 403 8 2 387 16 4.1
Pishin 300 1287 20 1.6 629 7 1.1 658 13 2
Musakhel 250 1469 93 6.3 791 42 5.3 678 51 7.5
Tank 299 2032 25 1.2 999 13 1.3 1033 12 1.2
Charsada 399 2856 21 0.7 1451 5 0.3 1405 16 1.1
Nowshera 403 2288 9 0.4 1134 2 0.2 1154 7 0.6
D.I.Khan 350 2096 69 3.3 1036 42 4.1 1060 27 2.5
North Waziristan 247 1171 39 3.3 780 20 2.6 391 19 4.9
Orakzai 249 1732 33 1.9 970 22 2.3 762 11 1.4
Mohmand 300 2214 77 3.5 1158 30 2.6 1056 47 4.5
South Waziristan 300 1921 5 0.3 1249 4 0.3 672 1 0.1
FR Peshawar/Kohat 249 1459 34 2.3 810 16 2 649 18 2.8
FR Bannu/Lakki 150 982 45 4.6 509 21 4.1 473 24 5.1
FR Tank/DI Khan 200 838 15 1.8 590 8 1.4 248 7 2.8
Total 5345 31318 717 2.3 16908 352 2.1 14410 365 2.5
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Table 92: Prevalence of fever at the time of survey by age in Round 10 districts
Under 5 years 5-14 years 15 + years District No. of No. of No. of Fever % Fever % Fever subject subject subject Tando Allah Yar 200 17 8.5 501 14 2.8 895 12 1.3 Mirpurkhas 317 20 6.3 580 19 3.3 1102 8 0.7 Panjgur 176 13 7.4 473 34 7.2 1227 20 1.6 Kharan 204 3 1.5 414 2 0.5 685 8 1.2 Chaghi 210 14 6.7 428 11 2.6 743 12 1.6 Washhuk 93 3 3.2 225 3 1.3 472 18 3.8 Pishin 152 3 2.0 427 4 0.9 708 13 1.8 Musakhel 237 14 5.9 467 19 4.1 765 60 7.8 Tank 250 4 1.6 600 8 1.3 1182 13 1.1 Charsada 343 4 1.2 785 4 0.5 1715 13 0.8 Nowshera 342 3 0.9 586 1 0.2 1356 5 0.4 D.I.Khan 294 6 2.0 638 20 3.1 1164 43 3.7 North Wazirastan 208 8 3.8 386 25 6.5 577 6 1.0 Orakzai 241 7 2.9 549 6 1.1 942 20 2.1 Mohmand 361 19 5.3 726 22 3.0 1127 36 3.2 South Waziristan 108 0 0.0 463 3 0.6 1348 2 0.1 FR 162 4 2.5 451 11 2.4 843 19 2.3 Peshawar/Kohat FR Bannu/Lakki 144 6 4.2 295 17 5.8 543 22 4.1 FR Tank/DI Khan 116 2 1.7 346 8 2.3 376 6 1.6 Total 4158 150 3.6 9340 231 2.5 17770 336 1.9
Table 93: Prevalence of Malaria (Microscopy and/or RDTs) in 19 districts of Round 10 by age
Total Under 5 yrs 5-14 yrs 15-49 yrs 50 * yrs
Tested +ve Tested +ve Tested +ve Tested +ve Tested +ve
Sindh 2749 5 385 0 870 0 1317 5 175 0 (0.18 %) (0.38%)
Balochistan 5316 60 791 11 1852 24 2354 24 318 1 (0.31%) (1.13%) (1.39%) (1.30%) (1.02%)
KPK 6853 86 1007 13 2102 28 3041 38 690 7 (1.01%) (1.25%) (1.29%) (1.33%) (1.25%)
FATA 7497 206 1029 28 2395 79 3492 82 581 17 (2.93%) (2.75%) (2.72%) (3.30%) (2.35%)
Total 22415 357 3212 52 7219 131 10204 149 1764 25 (1.59%) (1.62%) (1.81%) (1.46%) (1.42%)
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10.12.1. Fever cases positive on RDTs Table 94: Results of RDT in fever cases in 19 districts of Round-10 RDT Type of malaria Fever Positive Districts Household Individuals RDT done No. % Via Falciparum Mixed
Tando Allah Yar 294 1600 40 1 2.5 0 1 0
Mirpurkhas 397 1999 45 1 2.2 1 0 0
Panjgur 300 1879 67 1 1.5 0 1 0
Kharan 220 1324 14 2 14.3 2 0 0
Chaghi 250 1381 37 8 21.6 8 0 0
Washhuk 188 790 24 3 12.5 3 0 0
Pishin 300 1287 20 0 0.0 0 0 0
Musakhel 250 1469 91 6 6.6 1 2 3
Tank 299 2032 29 5 17.2 5 0 0
Charsada 399 2856 22 2 9.1 2 0 0
Nowshera 403 2288 10 1 10.0 0 1 0
D.I.Khan 350 2096 68 0 0.0 0 0 0
North Wazirastan 247 1171 39 14 35.9 7 7 0
Orakzai 249 1732 33 3 9.1 3 0 0
Mohmand 300 2214 77 5 6.5 4 1 0
South Waziristan 300 1921 6 1 16.7 1 0 0 FR 249 1459 34 2 5.9 2 0 0 Peshawar/Kohat FR Bannu/Lakki 150 982 44 6 13.6 6 0 0
FR Tank/DI Khan 200 838 17 11 64.7 1 4 6
Total 5345 31318 717 72 10.0 46 17 9
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Table 95: Results of RDTs by gender in Round-10 districts
Male Female Districts RDT RDT Individuals Positive % Individuals Positive % done done
Tando Allah Yar 841 21 0 0.0 759 19 1 5.3
Mirpurkhas 1048 23 1 4.3 951 22 0 0.0
Panjgur 1084 41 0 0.0 795 26 1 3.8
Kharan 694 6 1 16.7 630 8 1 12.5
Chaghi 732 18 7 38.9 649 19 1 5.3
Washhuk 403 8 1 12.5 387 16 2 12.5
Pishin 629 7 0 0.0 658 13 0 0.0
Musakhel 791 42 3 7.1 678 49 3 6.1
Tank 999 14 1 7.1 1033 15 4 26.7
Charsada 1451 6 1 16.7 1405 16 1 6.3
Nowshera 1134 3 1 33.3 1154 7 0 0.0
D.I.Khan 1036 42 0 0.0 1060 26 0 0.0
North Wazirastan 780 20 10 50.0 391 19 4 21.1
Orakzai 970 22 2 9.1 762 11 1 9.1
Mohmand 1158 30 2 6.7 1056 47 3 6.4
South Waziristan 1249 5 1 20.0 672 1 0 0.0
FR Peshawar/Kohat 810 16 1 6.3 649 18 1 5.6
FR Bannu/Lakki 509 20 3 15.0 473 24 3 12.5
FR Tank/DI Khan 590 9 5 55.6 248 8 6 75.0
Total 16908 353 40 11.3 14410 364 32 8.8
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10.13. HOT SPOTS/HIGH RISK DISTRICTS Table 96: Microscopy results by Union Council in 19 districts of Round-10
Overall Blood smear results No. of District Name Union Council Positive on Negative SPR Individuals Microscopy Vivax Falciparum Mixed Tando Allah Yar Bukera Sharif 206 0 0 206 0.0 Chamber 164 1 1 163 0.6 Dasori 215 0 0 215 0.0 Missan 199 0 0 199 0.0 Sheikh Moosa 236 0 0 236 0.0 UC-3 206 0 0 206 0.0 Mirpurkhas Kangoro 214 0 0 214 0.0 Khan 209 2 2 207 1.0 Khudad 159 0 0 159 0.0 MakhanSamoo 228 0 0 228 0.0 Meerwah 190 0 0 190 0.0 Nankot 178 1 1 177 0.6 Soffan Shah 196 0 0 196 0.0 U-C 8 MPK 149 0 0 149 0.0 Panjgur Bonistan 96 0 96 0.0 Chitkan 106 0 106 0.0 Gram Kan 86 0 86 0.0 Kallag 108 0 108 0.0 Sordo 90 0 90 0.0 Tasp 99 0 99 0.0 Kharan Janobicit 221 0 0 221 0.0 Mooryali 206 1 1 205 0.5 Raaskoh 276 0 0 276 0.0 Sarawan 222 0 0 222 0.0 TohMalak 133 0 0 133 0.0 Chaghi Amin Abad 245 0 0 245 0.0 Amri 190 0 0 190 0.0 Nokkundi 176 0 0 176 0.0 Padag 208 8 8 200 3.8 Z. Balanosh 199 0 0 199 0.0 Washhuk Beema 200 5 5 195 2.5 Garrang 118 0 0 118 0.0 Plantak 156 0 0 156 0.0 Sohtagan 111 0 0 111 0.0 Soldan 97 3 3 94 3.1 Pishin Ali Zai 181 0 0 181 0.0 B.Barshor 206 0 0 206 0.0 Barshor 224 0 0 224 0.0 KhanoZaiKariz 206 0 0 206 0.0 Manzari 241 1 1 240 0.4 Shakarzai 163 0 0 163 0.0
135
Overall Blood smear results No. of District Name Union Council Positive on Negative SPR Individuals Microscopy Vivax Falciparum Mixed Musakhel Durak 142 3 2 0 1 139 2.1 Guryasa 149 11 3 8 0 138 7.4 Kangri 150 2 0 2 0 148 1.3 Musa Khawa 158 20 9 10 1 138 12.7 Saddar Bazar 153 0 0 0 0 153 0.0 Tank City-2 262 0 0 262 0.0 Dabara 291 6 6 285 2.1 Dabra 1 0 0 1 0.0 GulInam 243 14 14 229 5.8 Ranwal 269 0 0 269 0.0 Shah Alam 248 12 12 236 4.8 Sheikh Uttar 317 1 1 316 0.3 Charsada Agra 158 0 0 158 0.0 Behlola 328 0 0 328 0.0 Dhakki 267 0 0 267 0.0 Dolatpura 216 2 2 214 0.9 Haji Zai 214 4 4 210 1.9 HesarNeh 282 12 12 270 4.3 Mera Prang 305 0 0 305 0.0 Shabqadar 270 0 0 270 0.0 Nowshera AmanKot 238 3 3 235 1.3 Dag Behsud 255 0 0 255 0.0 Jehangira 247 2 2 245 0.8 Kaka Sahib 186 0 0 186 0.0 Khairabad 130 8 8 122 6.2 Manki Sharif 51 4 4 47 7.8 Nawan Kali 239 0 0 239 0.0 PirPai 198 0 0 198 0.0 D.I.Khan D.I Khan III-Ur 217 0 0 0 217 0.0 GaraEssa 229 0 0 0 229 0.0 Giloti 299 5 4 1 294 1.7 Kath Garh 216 2 2 0 214 0.9 LAR 208 4 4 0 204 1.9 Mohra 229 0 0 0 229 0.0 Zindani 240 2 2 0 238 0.8 North Mir Ali 125 9 9 116 7.2 Wazirastan Miran Shah 190 12 12 178 6.3 Razmak 221 24 24 197 10.9 Shiwa 250 25 25 225 10.0 Spin Wam 247 11 11 236 4.5 Orakzai BarhamZai 121 0 0 121 0.0 CHC Zira 214 0 0 214 0.0 Char kila 105 2 2 103 1.9 Mehsti 129 0 0 129 0.0 Sulemankh 230 3 3 227 1.3 Mohmand Banglow 285 8 8 0 277 2.8 Barokhel 247 5 5 0 242 2.0 Danish Kool 324 3 3 0 321 0.9 Hamzakhel 265 6 5 1 259 2.3 Kangri 6 0 0 0 6 0.0 Kar Kana 332 7 5 2 325 2.1 Lakaro 217 0 0 0 217 0.0
136
Overall Blood smear results No. of District Name Union Council Positive on Negative SPR Individuals Microscopy Vivax Falciparum Mixed
South 0.0 Waziristan Barmal 207 0 0 207 Mughal Khel 170 0 0 170 0.0 Shakai 149 0 0 149 0.0 Spin 238 3 3 235 1.3 Tuikhela 261 9 9 252 3.4 WanaDabkot 236 0 0 236 0.0 FR 0.9 Peshawar/Kohat Akhorwal 225 2 2 223 Ashokhel 323 0 0 323 0.0 DaleelKhel 231 4 4 227 1.7 Mandai 279 0 0 279 0.0 ZarghunKhel 147 1 1 146 0.7 FR Bannu/Lakki DarakaSuleman 200 1 1 199 0.5 Daryaba 267 7 7 260 2.6 FR Tajori 224 9 9 215 4.0 FR Tank/DI 0.0 Khan Drazinda 223 0 0 0 0 223 KehviBhara 163 0 0 0 0 163 0.0 Mughal Kot 179 23 3 19 1 156 12.8 Ping 267 4 4 0 0 263 1.5 Total 22415 317 271 43 3 22098 1.4
137
HEALTH FACILITY SURVEY
10.14. STAFF WORKING FOR MALARIA AT THE HEALTH FACILITIES Table 97: Staff working for malaria at Health facility by province and district (2012)
BHU RHC THQ DHQ HF No. MO Staff No. MO Staff No. MO Staff No. MO Staff 20 12 4 2 6 5 4 4 6 districts 39 20 4 6 4 100.0 60.0 100.0 50.0 100.0 83.3 100.0 100.0 Sindh 14 8 3 2 4 4 4 4 4 4 districts (R-07) 25 14 3 4 100.0 57.1 100.0 66.7 100.0 100.0 100.0 100.0 6 4 1 0 2 1 2 districts (R-10) 14 6 1 2 0 100.0 66.7 100.0 0.0 100.0 50.0 43 18 14 7 9 2 2 7 7 15 districts 86 15 3 12 41.9 32.6 46.7 60.0 66.7 66.7 58.3 58.3 Baloc. 23 17 14 7 9 2 2 6 7 9 districts (R-07) 52 9 2 7 73.9 60.9 77.8 100.0 100.0 100.0 85.7 100.0
20 1 0 0 0 0 0 1 0 6 districts (R-10) 34 6 1 5 5.0 0.0 0.0 0.0 0.0 0.0 20.0 0.0 16 4 2 3 3 1 1 3 3 7 districts 33 7 3 7 25.0 12.5 42.9 42.9 33.3 33.3 42.9 42.9 KPK 8 0 0 0 0 0 0 1 1 3 districts (R-07) 14 2 1 3 0.0 0.0 0.0 0.0 0.0 0.0 33.3 33.3
8 4 2 3 3 1 1 2 2 4 districts (R-10) 19 5 2 4 50.0 25.0 60.0 60.0 50.0 50.0 50.0 50.0 22 1 3 2 2 0 1 0 1 10 districts 40 5 5 5 4.5 13.6 40.0 40.0 0.0 20.0 0.0 20.0 FATA 5 1 2 2 2 0 0 0 0 3 districts (R-07) 12 2 1 1 20.0 40.0 100.0 100.0 0.0 0.0 0.0 0.0 0 1 0 0 0 1 0 1 7 districts (R-10) 28 17 3 4 4 0.0 5.9 0.0 0.0 0.0 25.0 0.0 25.0 38 districts 43 31 16 16 9 9 14 16 198 101 31 17 28 42.6 30.7 51.6 51.6 52.9 52.9 50.0 57.1 32 24 12 13 6 6 11 12 Total 19 districts (R-07)103 50 16 8 15 64.0 48.0 75.0 81.3 75.0 75.0 73.3 80.0 19 districts (R-10) 95 51 11 7 15 4 3 3 3 3 4 9 13 21.6 13.7 26.7 20.0 33.3 33.3 23.1 30.8 Other health facility = 9, MO=Medical Officer, Staff=Lab. Tech / Microcopist / CDC
138
Table 98: Staff working for malaria at Health facility by province and district (2013)
BHU RHC THQ DHQ Province District HF No. MO Staff No. MO Staff No. MO Staff No. MO Staff
18 11 4 2 6 5 4 5 6 districts 39 20 4 6 5
90.0 61.1 100.0 50.0 100.0 83.3 80.0 100.0
4 districts 12 8 3 2 4 4 4 4 25 14 3 4 4 (R-07) Sindh 85.7 66.7 100.0 66.7 100.0 100.0 100.0 100.0 2 districts 6 3 1 0 2 1 0 1 14 6 1 2 1 (R-10) 100.0 50.0 100.0 0.0 100.0 50.0 0.0 100.0 32 23 9 15 1 3 7 13 15 districts 86 48 19 3 14 66.7 71.9 47.4 78.9 33.3 100.0 50.0 92.9 9 districts 23 14 8 10 1 2 6 8 52 28 13 2 9 (R-07) 82.1 60.9 61.5 76.9 50.0 100.0 66.7 88.9
Balochistan 6 districts 9 9 1 5 0 1 1 5 34 20 6 1 5 (R-10) 45.0 100.0 16.7 83.3 0.0 100.0 20.0 100.0 15 15 5 7 3 3 5 7 7 districts 33 16 7 3 7 93.8 100.0 71.4 100.0 100.0 100.0 71.4 100.0 3 districts 8 8 2 2 1 1 2 3 14 8 2 1 3
KPK (R-07) 100.0 100.0 100.0 100.0 100.0 100.0 66.7 100.0 4 districts 7 7 3 5 2 2 3 4 19 8 5 2 4 (R-10) 87.5 100.0 60.0 100.0 100.0 100.0 75.0 100.0 20 22 4 5 4 5 4 5 10 districts 40 22 5 5 5
90.9 110.0 80.0 100.0 80.0 100.0 80.0 100.0
3 districts 4 5 1 2 1 1 1 1 12 5 2 1 1 (R-07) FATA 80.0 125.0 50.0 100.0 100.0 100.0 100.0 100.0 7 districts 16 17 3 3 3 4 3 4 28 17 3 4 4 (R-10) 94.1 106.3 100.0 100.0 75.0 100.0 75.0 100.0 38 85 71 22 29 14 16 20 30 198 106 35 17 31 districts 80.2 83.5 62.9 82.9 82.4 94.1 64.5 96.8
19 47 35 14 16 7 8 13 16 districts 103 55 20 8 17
Total (R-07) 85.5 74.5 70.0 80.0 87.5 100.0 76.5 94.1 19 38 36 8 13 7 8 7 14 districts 95 51 15 9 14 (R-10) 74.5 94.7 53.3 86.7 77.8 88.9 50.0 100.0 Other health facility = 9, MO=Medical Officer, Staff=Lab.Tech/Microcopist/CDC
139
10.15. EQUIPMENT AND SUPPLIES POSITION Table 99: Number and percentage of BHUs with all inputs for RDT Centre in place by districts (2013)
District Total BHUs Doing RDT Tharparkar/Mithi 4 3 Khairpur 4 1 Thatta 3 2 Dadu 3 0 Tando Allah Yar 4 4 Mirpurkhas 2 2 Zhob/Sheran 4 2 Noushki 3 2 Gawadar 3 1 Kech 4 4 Sibi/Harnai 3 1 Kila Saifullah 3 2 Nasirabad 3 2 Loralai 3 2 Mastung 3 0 Panjgur 5 1 Kharan 5 4 Chaghi 1 1 Washhuk 3 3 Pishin 2 1 Musakhel 3 0 Lakki Marwat 3 1 Bannu 3 0 Mardan 2 0 Tank 2 2 Charsada 2 2 Nowshera 2 2 D.I.Khan 2 1 Kurram 3 1 Khyber 1 1 Bajaur 1 0 North Wazirastan 1 1 Orakzai 3 0 Mohmand 2 1 South Waziristan 3 1 FR Peshawar/Kohat 2 1 FR Bannu/Lakki 4 0 FR Tank/DI Khan 2 0 Total 106 52
140
10.16. ANTI-MALARIA DRUGS AND LLINS OUT OF STOCK (Aug-Oct) Table 100: Overall Stock out of Anti Malarial and RDTs during three months (August, September, October) 2013
Year 2013 Districts HF CQ PQ AS Inj. ACT A-L Q. Tab RDT
OOSt 3 (2.5) 4 (3.2) 3 (37.5) 0 (0.0) 5 (41.7) 2 (2.2) 2 (6.3) 38 districts 198 IA-FM2 120 124 8 116 12 90 32
OOSt 2 (34) 2 (3.2) 1 (100) 0 (0.0) 1 (33.3) 1 (2.3) 1 (8.3) 19 districts August 103 (R-07) IA-FM2 59 62 1 56 3 43 12
OOSt 1 (1.6) 2 (3.2) 2 (28.6) 0 (0.0) 3 (33.3) 1 (2.1) 1 (5.0) 19 districts 95 (R-10) IA-FM2 61 62 7 60 9 47 20
OOSt 3 (2.6) 1 (0.9) 5 (7.5) 0 (100) 4 (28.6) 2 (2.4) 3 (9.4) 38 districts 198 IA-FM2 114 114 67 105 14 84 32
OOSt 1 (1.8) 0 (0.0) 1 (3.6) 0 (100) 1 (25.0) 0 (0.0) 2 (18.2) 19 districts September 103 (R-07) IA-FM2 55 54 28 47 4 40 11
OOSt 2 (3.4) 0 (0.0) 4 (10.3) 0 (100) 3 (30.0) 2 (4.5) 1 (4.8) 19 districts 95 (R-10) IA-FM2 59 60 39 58 10 44 21
OOSt 4 (4.4) 4 (4.3) 8 (14.3) 1 (1.3) 6 (42.9) 5 (7.6) 2 (8.3) 38 districts 198 IA-FM2 91 93 56 80 14 66 24
OOSt 3 (7.0) 4 (9.3) 3 (15.0) 1 (2.9) 4 (66.7) 3 (10.3) 2 (28.6) 19 districts October 103 (R-07) IA-FM2 43 43 20 34 6 29 7
OOSt 1 (2.1) 0 (0.0) 5 (13.9) 0 (0.0) 2 (25.0) 2 (5.4) 0 (0.0) 19 districts 95 (R-10) IA-FM2 48 50 36 46 8 37 17
141
Table 101: Stock out of Anti Malarial and RDTs in August 2013 in 38 districts
August 2013 CQ PQ AS Inj. ACT Q. Tab RDTs IA- FM St. IA- St. IA- St. IA- St. IA- St. IA- St. Districts 2 Out FM2 Out FM2 Out FM2 Out FM2 Out FM2 Out Tharparkar/Mithi 2 0 3 0 2 0 3 0 2 0 Khairpur 5 0 4 0 2 0 Thatta 5 1 4 1 1 0 3 0 2 0 Dadu 2 0 3 0 2 0 2 0 Tando Allah Yar 5 0 5 1 4 0 2 0 1 1 Mirpurkhas 5 1 6 0 1 1 6 0 3 1 4 0 Zhob/Sheran 4 0 4 0 4 0 4 0 4 0 2 0 Noushki 5 0 5 0 5 0 5 0 5 0 2 0 Gawadar Kech 2 0 3 0 3 0 2 0 Sibi/Harnai 5 0 5 0 3 0 5 0 2 0 1 0 Kila Saifullah 2 0 2 0 2 0 1 0 2 0 Nasirabad 5 0 6 0 5 0 6 0 5 0 3 1 Loralai 2 2 0 Mastung 2 0 2 0 1 0 2 0 1 0 Panjgur 4 0 4 0 2 0 5 0 2 0 Kharan Chaghi Washhuk 4 0 4 0 4 0 1 0 4 0 Pishin 4 0 4 0 3 0 4 0 4 0 2 0 Musakhel 2 0 2 0 2 0 2 0 2 0 Lakki Marwat 5 1 5 0 5 0 5 1 1 0 Bannu 4 0 4 1 3 0 4 0 4 0 Mardan 4 0 4 0 2 0 4 0 4 0 Tank 5 0 5 0 5 0 5 0 5 0 5 0 Charsada 5 0 5 0 5 1 5 0 5 0 Nowshera 4 0 4 0 3 0 4 0 3 0 D.I.Khan 3 0 3 0 3 0 3 0 Kurram 3 0 4 0 1 0 3 0 1 0 1 0 Khyber 4 0 4 0 3 0 4 0 4 0 Bajaur ------North Wazirastan 4 0 4 0 4 0 2 0 4 0 1 0 Orakzai 3 0 3 0 3 0 3 0 3 0 Mohmand 2 0 2 1 2 1 2 0 2 0 South Waziristan 3 0 3 0 1 0 3 0 2 0 FR Peshawar/Kohat 4 0 4 0 4 0 4 0 4 0 1 0 FR Bannu/Lakki 3 0 3 0 3 0 3 0 3 0 FR Tank/DI Khan 1 0 1 0 1 0 1 0 1 0 Total 120 3 124 4 73 5 116 0 90 2 32 2 IA-FM2 = Information available in FM2, St. Out = Stock out
142
Table 102: Stock out of Anti Malarial and RDTs in September 2013 in 38 districts CQ PQ AS Inj. ACT Q. Tab RDTs
IA- St. IA- St. IA- St. IA- St. IA- St. IA- St. September 2013 FM2 Out FM2 Out FM2 Out FM2 Out FM2 Out FM2 Out Tharparkar/Mithi 2 0 2 0 2 0 2 0 2 0 Khairpur 5 0 4 0 1 0 Thatta 6 0 5 0 1 0 3 0 2 0 Dadu 3 0 3 0 2 0 2 0 Tando Allah Yar 5 0 5 1 4 0 2 0 1 1 Mirpurkhas 4 0 5 0 1 1 5 0 2 1 4 0 Zhob/Sheran 5 0 5 0 5 0 5 0 5 0 3 0 Noushki 5 0 5 0 5 0 5 0 5 0 4 2 Kech 2 0 3 0 1 0 3 0 2 0 2 0 Sibi/Harnai 2 0 2 0 1 0 2 0 2 0 1 0 Kila Saifullah 1 0 1 0 1 0 1 0 1 0 Nasirabad 2 0 2 0 2 0 2 0 2 0 Loralai 1 0 1 0 3 2 1 0 1 0 Mastung 2 0 2 0 2 0 Panjgur 4 0 4 0 2 1 5 0 2 0 Kharan Chaghi Washhuk 4 0 4 0 4 0 4 0 Pishin 2 0 2 0 2 0 2 0 2 0 1 0 Musakhel 2 0 2 0 2 0 2 0 2 0 Lakki Marwat 3 0 3 0 3 0 3 0 Bannu 4 0 4 0 2 0 4 0 4 0 Mardan 4 0 4 0 2 0 4 0 4 0 Tank 5 0 5 0 5 0 5 0 5 0 5 0 Charsada 3 0 3 0 3 0 3 0 3 0 Nowshera 4 0 4 0 2 0 4 0 3 0 D.I.Khan 4 0 4 0 1 0 4 0 4 0 1 0 Kurram 4 0 4 0 1 0 3 0 1 0 1 0 Khyber 4 0 4 0 3 0 4 0 4 0 Bajaur ------North Wazirastan 4 0 4 0 4 0 2 0 4 0 Orakzai 4 0 4 0 4 0 4 0 4 0 Mohmand 1 0 1 0 1 0 1 0 1 0 South Waziristan 4 0 4 0 2 1 4 0 3 1 2 0 FR Peshawar/Kohat 3 0 3 0 3 0 3 0 3 0 1 0 FR Bannu/Lakki 4 0 4 0 4 0 4 0 4 0 FR Tank/DI Khan 2 0 2 0 2 0 2 0 2 0 Total 114 0 114 1 67 5 105 0 84 2 32 3 IA-FM2 = Information available in FM2, St. Out = Stock out
143
Table 103: Stock out of Anti Malarial, and RDTs in October 2013 in 38 districts
CQ PQ AS Inj. ACT Q. Tab RDTs IA- St. IA- St. IA- St. IA- St. IA- St. IA- St. October 2013 FM2 Out FM2 Out FM2 Out FM2 Out FM2 Out FM2 Out Tharparkar/Mithi Khairpur 5 4 0 2 0 Thatta 5 4 0 1 0 2 0 2 0 Dadu 3 1 3 1 Tando Allah Yar 4 4 0 3 0 1 0 Mirpurkhas 4 1 5 0 1 1 5 0 2 1 4 0 Zhob/Sheran 1 1 2 1 2 1 2 1 2 1 Noushki 5 5 0 5 0 5 0 4 0 3 1 Kech 1 0 1 0 1 0 Sibi/Harnai 1 1 Kila Saifullah 1 1 0 1 0 Nasirabad 1 1 0 1 0 1 0 1 0 Loralai 2 2 Mastung Panjgur 1 1 0 1 0 1 0 Kharan 1 0 Chaghi Washhuk 4 4 0 4 0 4 0 Pishin 1 1 0 1 0 1 0 1 0 1 0 Musakhel Lakki Marwat 5 5 1 1 1 5 0 5 2 1 0 Bannu 5 1 5 1 3 0 5 0 5 0 Mardan 4 4 0 2 0 4 0 4 0 Tank 5 5 0 5 0 5 0 5 0 5 0 Charsada 4 4 0 4 1 4 0 4 0 Nowshera 2 2 0 2 0 2 0 2 0 D.I.Khan Kurram 4 4 0 1 0 3 0 1 0 1 0 Khyber 4 4 0 3 0 4 0 4 0 Bajaur ------North Wazirastan 4 4 0 4 0 2 0 4 0 Orakzai 4 4 0 4 0 4 0 4 0 Mohmand 1 1 0 1 0 1 0 1 0 South Waziristan 4 4 0 2 2 4 0 3 1 2 0 FR 4 4 0 4 4 Peshawar/Kohat 4 0 0 0 1 0 FR Bannu/Lakki 4 4 0 4 0 4 0 4 0 FR Tank/DI Khan 2 2 0 2 0 2 0 2 0 Total 91 4 93 4 56 8 80 1 66 5 24 2 IA-FM2 = Information available in FM2, St. Out = Stock out
144
10.17. MALARIA CASE MANAGEMENT PRACTICES Table 104: Malaria Diagnosis Practices (microscopy) at RHCs, THQs and DHQs in the surveyed facility in 38 districts Are you doing malaria If no, How malaria is District Health facility microscopy in your facility confirmed Yes No Referred DK Tharparkar/Mithi 3 3 0 Khairpur 2 2 0 Thatta 3 3 0 Dadu 3 3 0 Tando Allah Yar 3 2 1 1 Mirpurkhas 1 1 0 Zhob/Sheran 2 2 0 Noushki 2 2 0 Gawadar 1 1 0 Kech 2 1 1 1 Sibi/Harnai 3 3 0 Kila Saifullah 3 2 1 1 Nasirabad 3 3 0 Loralai 5 4 1 1 Mastung 3 3 0 Panjgur 1 1 0 Kharan 1 1 0 Chaghi 2 2 0 Washhuk 2 1 1 0 1 Pishin 4 3 1 1 0 Musakhel 2 2 0 Lakki Marwat 2 2 0 Bannu 2 2 0 Mardan 2 2 0 Tank 3 3 0 Charsada 3 3 0 Nowshera 2 2 0 D.I.Khan 3 3 0 Kurram 1 1 0 Bajaur 3 3 0 North Wazirastan 3 3 0 Orakzai 1 1 0 Mohmand 2 2 0 South Waziristan 1 1 0 FR Peshawar/Kohat 2 2 0 FR Tank/DI Khan 2 2 0 Total 83 77 6 4 2
145
Table 105: Malaria Diagnosis Practices (RDTs) in the surveyed facility (BHUs) in 38 districts (2013)
Are you doing RDT If no, How malaria is confirmed Health testing in your facility District Treat Don’t Facility Yes No Referred clinical know Tharparkar/Mithi 4 3 1 0 1 0 Khairpur 4 1 3 0 1 2 Thatta 2 2 0 0 0 0 Dadu 2 0 2 0 1 1 Tando Allah Yar 4 4 0 0 0 0 Mirpurkhas 2 2 0 0 0 0 Zhob/Sheran 4 2 2 0 1 1 Noushki 3 2 1 0 0 1 Gawadar 1 1 0 0 0 0 Kech 4 4 0 0 0 0 Sibi/Harnai 2 1 1 1 0 0 Kila Saifullah 3 2 1 1 0 0 Nasirabad 3 2 1 0 0 1 Loralai 2 2 0 0 0 0 Mastung 2 0 2 0 2 0 Panjgur 4 1 3 0 1 2 Kharan 5 4 1 0 1 0 Chaghi 1 1 0 0 0 0 Washhuk 3 3 0 0 0 0 Pishin 1 1 0 0 0 0 Musakhel 1 0 1 0 0 1 Lakki Marwat 3 1 2 2 0 0 Bannu 3 0 3 3 0 0 Mardan 2 0 2 2 0 0 Tank 2 2 0 0 0 0 Charsada 2 2 0 0 0 0 Nowshera 2 2 0 0 0 0 D.I.Khan 2 1 1 0 0 1 Kurram 3 1 2 2 0 0 Khyber 1 1 0 0 0 0 Bajaur 1 0 1 0 0 1 North Wazirastan 1 1 0 0 0 0 Orakzai 3 0 3 3 0 0 Mohmand 2 1 1 1 0 0 South Waziristan 3 2 1 1 0 0 FR Peshawar/Kohat 2 1 1 1 0 0 FR Bannu/Lakki 3 0 3 2 0 1 FR Tank/DI Khan 2 0 2 2 0 0 Total 94 53 41 21 8 12
146
Table 106: Time elapse between the smear taken and result received at microscopy centres (n=80) by districts
How much time generally elapses between District Health Facility the smear taken and result received Same day Second day Tharparkar/Mithi 3 3 0 Khairpur 2 2 0 Thatta 3 3 0 Dadu 3 3 0 Tando Allah Yar 2 2 0 Mirpurkhas 1 1 0 Zhob/Sheran 2 2 0 Noushki 2 2 0 Gawadar 1 1 0 Kech 2 2 0 Sibi/Harnai 3 3 0 Kila Saifullah 3 3 0 Nasirabad 3 3 0 Loralai 5 5 0 Mastung 3 3 0 Panjgur 1 1 0 Kharan 1 1 0 Chaghi 2 2 0 Pishin 4 4 0 Musakhel 2 2 0 Lakki Marwat 2 2 0 Bannu 2 2 0 Mardan 2 2 0 Tank 3 3 0 Charsada 3 3 0 Nowshera 2 2 0 D.I.Khan 3 3 0 Kurram 1 1 0 Bajaur 3 3 0 North Wazirastan 3 3 0 Orakzai 1 1 0 Mohmand 2 2 0 South Waziristan 1 1 0 FR Peshawar/Kohat 2 2 0 FR Tank/DI Khan 2 2 0 Total 80 80 0
147
Table 107: Time elapse between the result received and treatment started How much time generally elapses between the Reporting HFs result received treatment started ? Same day Second day Tharparkar/Mithi 3 3 0 Khairpur 3 3 0 Thatta 4 4 0 Dadu 4 4 0 Tando Allah Yar 3 3 0 Mirpurkhas 7 7 0 Zhob/Sheran 3 3 0 Noushki 4 4 0 Gawadar 3 3 0 Kech 6 5 1 Sibi/Harnai 6 6 0 Kila Saifullah 6 5 1 Nasirabad 6 6 0 Loralai 7 7 0 Mastung 5 5 0 Panjgur 5 5 0 Kharan 6 6 0 Chaghi 4 4 0 Pishin 6 6 0 Musakhel 3 3 0 Lakki Marwat 5 5 0 Bannu 5 5 0 Mardan 4 4 0 Tank 5 5 0 Charsada 5 5 0 Nowshera 4 4 0 D.I.Khan 5 5 0 Kurram 4 4 0 Khyber 4 4 0 Bajaur 4 4 0 North Wazirastan 4 4 0 Orakzai 4 4 0 Mohmand 4 4 0 South Waziristan 4 4 0 FR Peshawar/Kohat 4 4 0 FR Bannu/Lakki 4 4 0 FR Tank/DI Khan 4 4 0 Total 168 166 2 Percent 98.8 1.2
148
Table 108: Referral of complicated malaria cases by surveyed health facilities in 38 districts Health Where do you refer complicated malaria cases? Facility
referring DHQ THQ Tertiary care cases Tharparkar/Mithi 7 3 3 1 Khairpur 4 2 0 2 Thatta 6 5 0 1 Dadu 3 0 2 1 Tando Allah Yar 1 1 0 0 Mirpurkhas 0 0 0 0 Zhob/Sheran 6 6 0 0 Noushki 5 4 0 1 Gawadar 3 3 0 0 Kech 6 5 0 1 Sibi/Harnai 6 5 0 1 Kila Saifullah 5 3 0 2 Nasirabad 6 5 0 1 Loralai 7 5 0 2 Mastung 6 5 0 1 Panjgur 5 4 0 1 Kharan 6 5 0 1 Chaghi 4 4 0 0 Washhuk 1 1 0 0 Pishin 6 4 1 1 Musakhel 3 2 0 1 Lakki Marwat 4 4 0 0 Bannu 5 5 0 0 Mardan 3 3 0 0 Tank 5 5 0 0 Charsada 4 4 0 0 Nowshera 3 3 0 0 D.I.Khan 5 5 0 0 Kurram 4 4 0 0 Khyber 3 0 0 3 Bajaur 4 4 0 0 North Wazirastan 4 4 0 0 Orakzai 4 4 0 0 Mohmand 3 3 0 0 South Waziristan 3 3 0 0 FR Peshawar/Kohat 2 2 0 0 FR Bannu/Lakki 4 4 0 0 FR Tank/DI Khan 3 3 0 0 Total 159 132 6 21 Percent 83.0 3.8 13.2
149
Table 109: Facilities having National malaria guidelines (2012)
Total HF having Case Province District Microscopy RDT MIS LLINs HF guidelines Management 6 districts 22 13 8 10 6 39 38
57.9 34.2 21.1 26.3 15.8 Sindh 4 districts 13 9 2 4 3 25 24 (R-07) 54.2 37.5 8.3 16.7 12.5
2 districts 9 4 6 6 3 14 14 (R-10) 64.3 28.6 42.9 42.9 21.4 30 23 19 26 29 15 districts 86 58 51.7 39.7 32.8 44.8 50.0 Balochistan 9 districts 29 22 19 26 29 (R-07) 52 46 63.0 47.8 41.3 56.5 63.0
6 districts 1 1 0 0 0 (R-10) 34 12 8.3 8.3 0.0 0.0 0.0 7 districts 0 0 0 0 0 33 0
0.0 0.0 0.0 0.0 0.0 KPK 3 districts 0 0 0 0 0 (R-07) 14 0 0.0 0.0 0.0 0.0 0.0
4 districts 0 0 0 0 0 (R-10) 19 0 0.0 0.0 0.0 0.0 0.0 10 districts 7 8 3 4 4 40 10
70.0 80.0 30.0 40.0 40.0 FATA 3 districts 4 5 3 4 4 (R-07) 12 7 57.1 71.4 42.9 57.1 57.1
7 districts 3 3 0 0 0 (R-10) 28 3 100.0 100.0 0.0 0.0 0.0 38 districts 59 44 30 40 39 198 103
57.3 42.7 29.1 38.8 37.9 Total 19 districts 46 36 24 34 36 103 77 (R-07) 59.7 46.8 31.2 44.2 46.8 13 8 6 6 3 19 districts 95 26 (R-10) 50.0 30.8 23.1 23.1 11.5
150
Table 110: Facilities having National malaria guidelines (2013)
Total HFs having Case Province District HF Guidelines Microscopy RDT MIS LLINs Management
29 13 14 15 7 6 districts 39 38 76.3 34.2 36.8 39.5 18.4 15 9 4 5 5 Sindh 4 districts 25 24 (R-07) 62.5 37.5 16.7 20.8 20.8
2 districts 14 4 10 10 2 (R-10) 14 14 100.0 28.6 71.4 71.4 14.3 59 42 33 60 50 15 districts 86 79 74.7 53.2 41.8 75.9 63.3 34 28 21 36 35 Balochistan 9 districts 52 52 (R-07) 65.4 53.8 40.4 69.2 67.3
6 districts 25 14 12 24 15 (R-10) 34 27 92.6 51.9 44.4 88.9 55.6 29 23 7 28 18 7 districts 33 30 96.7 76.7 23.3 93.3 60.0 10 10 1 11 9 KPK 3 districts 14 11 (R-07) 90.9 90.9 9.1 100.0 81.8
4 districts 19 13 6 17 9 (R-10) 19 19 100.0 68.4 31.6 89.5 47.4 17 16 5 14 11 10 districts 40 18 94.4 88.9 27.8 77.8 61.1 7 7 4 7 5 FATA 3 districts 12 7 (R-07) 100.0 100.0 57.1 100.0 71.4
7 districts 10 9 1 7 6 (R-10) 28 11 90.9 81.8 9.1 63.6 54.5 134 94 59 117 86 38 districts 198 165 81.2 57.0 35.8 70.9 52.1 19 districts 66 54 30 59 54 Total (R-07) 103 94 70.2 57.4 31.9 62.8 57.4 19 districts 68 40 29 58 32 (R-10) 95 71 95.8 56.3 40.8 81.7 45.1
151
10.18. MALARIA SITUATION Table 111: Malaria situation in 2012 – Microscopy (Sindh)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
(2012)
Total
OPD
No. No. of No. of
eatment PF PV Mixed
Months
No. No. of
Received
Total
Tr
Suspected Suspected
Referred No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS) (FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases
No. of HF 17 15 9 6 13 14 Jan 58525 3909 1686 0 355 3683 257 97 159 1 Feb 58525 3909 1686 0 355 3683 257 97 159 1 Mar 71449 5824 2709 0 468 5264 352 140 212 0 Apr 64925 4653 2271 0 543 4175 474 80 393 1 May 75568 6464 3727 0 1244 6179 1203 150 1045 8 Jun 76729 6582 3877 0 1395 6089 1334 102 1223 9 Jul 78888 6995 4280 0 1445 6938 1410 143 1263 4 Aug 84046 5865 3496 1 1247 5941 1207 265 940 2 Sep 82484 7485 4367 0 1486 7300 1435 473 951 11 Oct 85626 9002 5960 2 2558 9396 1702 575 1114 13 Nov 78147 5749 3596 0 1648 5754 744 310 421 13 Dec 77185 5153 2799 0 1175 4502 479 228 248 3
Table 112: Malaria situation in 2013 – Microscopy (Sindh)
1 2 3 4 5 6 7 8
No. of slides Positive in
2012
ia
(OPD)
(2012)
Total
OPD No. No. of
No. No. of PF PV Mixed
Months
No. No. of
Received
Total
Treatment
Suspected Suspected
Referred No. of Pt's
Anti Anti Malar
No. No. of slides
Positive
Malariacases
(FM2or DHIS) (FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No.HF 18 16 10 6 15 15 Jan 110422 4219 2193 0 273 3911 284 125 158 1 Feb 107665 4293 2730 0 178 4296 188 43 145 0 Mar 118011 5755 3243 0 297 5469 307 60 237 10 Apr 113994 5113 2389 0 392 4992 415 70 345 0 May 118707 5027 2611 0 548 5318 562 103 456 3 Jun 120475 5223 2574 0 573 5158 583 72 510 1 Jul 128282 5580 2690 0 743 5573 752 101 651 0 Aug 110022 6459 3441 0 791 6443 741 101 640 0 Sep 116524 7220 4177 0 700 7276 682 127 554 1 Oct 37302 3697 644 0 568 3175 371 92 273 6
152
Table 113: Malaria situation in 2012 – Microscopy (Balochistan)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
(2012)
Total cted
OPD No. No. of
No. No. of PF PV Mixed
Months
No. No. of
Received
Total
Treatment
Suspe Suspected
Referred No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS) (FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. of 24 26 26 10 26 26 HF Jan 49630 5222 4894 4 660 4891 493 237 255 1 Feb 46694 5740 5229 1 426 5181 410 186 222 2 Mar 55377 6298 6273 3 725 6387 728 378 349 1 Apr 60135 6019 5751 0 682 5888 704 314 382 8 May 66040 8007 7153 1185 1115 7134 838 265 572 1 Jun 67955 9193 6802 182 1183 7393 1207 388 794 25 Jul 69321 8335 6697 270 893 6692 972 283 645 44 Aug 61905 7775 6543 330 813 6607 856 308 535 13 Sep 63332 8549 7572 237 1158 7186 1055 466 584 5 Oct 54860 8041 6388 374 944 6121 1164 417 739 8 Nov 52830 5212 4527 0 700 4841 694 395 297 2 Dec 56267 4551 3498 5 410 3730 701 525 176 0
Table 114: Malaria situation in 2013 – Microscopy (Balochistan)
1 2 3 4 5 6 7 8
No. of slides Positive in
2012
(OPD)
(2012)
Total
OPD No. No. of
No. No. of PF PV Mixed
Months
No. No. of
Received
Total
Suspected Suspected
Treatment
Referred No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases
No. of 36 40 40 12 35 39 35 HF Jan 45557 4699 4624 0 572 4637 568 247 318 3 Feb 49018 5358 5133 0 579 5183 575 288 287 Mar 72243 6320 5936 11 968 5887 652 252 395 5 Apr 70883 6396 6207 0 733 6107 633 214 414 5 May 60494 6942 6637 8 1061 6370 755 244 510 1 Jun 64146 6220 6101 9 1203 5969 862 219 643 0 Jul 65736 6930 6295 31 1049 6315 998 217 772 9 Aug 72691 6398 6357 0 1108 6089 941 302 634 5 Sep 50657 8425 8188 6 1664 7874 1453 520 927 6 Oct 27744 4556 4398 1 928 4268 874 388 486 0
153
Table 115: Malaria situation in 2012 – Microscopy (KPK)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
(2012)
Total
OPD No. No. of
No. No. of PF PV Mixed
Months
No. No. of
Received
Total
Suspected Suspected
Treatment
Referred No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. of 9 9 9 9 9 9 HF Jan 2290 2290 0 143 2290 317 70 247 0 Feb 2553 2553 0 156 2553 332 53 279 0 Mar 3009 3009 0 201 3009 374 40 334 0 Apr 3342 3342 0 432 3342 615 30 580 5 May 3768 3768 0 495 3768 780 23 756 1 Jun 4010 4010 0 280 4010 951 52 899 0 Jul 3415 3415 0 240 3415 741 32 709 0 Aug 2775 2775 0 201 2775 522 15 507 0 Sep 3734 3734 0 237 3734 749 32 717 0 Oct 3180 3180 0 272 2712 696 52 644 0 Nov 3015 3015 0 459 3015 521 68 452 1 Dec 11136 2798 2798 0 266 2798 332 28 204 0
Table 116: Malaria situation in 2013 – Microscopy (KPK)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
(2012)
Total
OPD No. No. of
No. No. of PF PV Mixed
Months
reatment
No. No. of
Received
Total
Suspected Suspected
T
Referred No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. of 23 24 24 24 24 24 24 HF Jan 13298 2351 2351 19 245 2236 243 6 232 5 Feb 48166 4626 4626 0 980 4626 980 52 917 11 Mar 68851 4525 4525 14 436 4398 433 25 407 1 Apr 105456 5534 5532 0 539 5338 537 27 505 5 May 116557 6034 6023 29 617 6023 557 30 525 2 Jun 102452 5342 5340 0 698 5197 698 26 668 4 Jul 139054 7303 7301 0 920 7072 920 37 881 2 Aug 152858 7712 7712 0 1044 7542 1064 27 1037 0 Sep 98349 7131 7131 0 999 6812 999 23 973 3 Oct 69405 6224 6224 0 1143 6224 1143 44 1089 10
154
Table 117: Malaria situation in 2012 – Microscopy (FATA)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
ted
(2012)
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspec Suspected
Treatment
Referred No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. of 8 8 6 8 8 8 HF 5 Jan 15686 1836 1833 0 368 1833 370 124 242 4 Feb 25616 2286 2286 0 428 2286 428 71 347 10 Mar 28647 2530 2530 0 392 2530 396 62 327 7 Apr 35296 4457 4457 0 852 4438 852 25 817 10 May 100497 6036 6036 0 1265 6036 1269 6 1257 6 Jun 37020 6855 6855 0 1597 6855 1601 11 1586 4 Jul 35899 6847 6847 0 1751 6773 1751 14 1736 1 Aug 32337 5427 5427 0 1137 5427 1137 38 1085 14 Sep 29700 6786 6786 0 942 6786 942 39 886 17 Oct 30328 4497 4497 0 948 4497 946 118 822 6 Nov 20062 3620 3620 0 628 3620 628 178 431 19 Dec 19543 2502 2287 0 286 2572 286 64 214 8
Table 118: Malaria situation in 2013 – Microscopy (FATA)
1 2 3 4 5 6 7 8
No. of slides Positive in
2012
(OPD)
(2012)
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
ia cases ia
Received
Total
Suspected Suspected
Treatment
Referred No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malar No. of 30 33 33 31 33 33 33 HF Jan 25902 2552 2560 0 232 2560 232 37 195 0 Feb 39208 3152 3152 0 297 3151 312 60 252 0 Mar 41119 4286 4286 0 359 4262 369 22 342 5 Apr 49774 5276 5016 41 413 4980 333 30 303 0 May 47877 4951 4469 78 496 4396 514 30 474 10 Jun 48354 6348 5785 68 732 5725 801 27 765 9 Jul 50171 5713 5043 84 659 4967 685 23 660 2 Aug 49765 5705 5705 0 901 5660 917 71 837 9 Sep 55642 8440 7610 103 1857 7449 1864 425 1439 0 Oct 51079 8049 7473 80 1894 7351 1884 711 1171 2
155
Table 119: Malaria situation (RDTs ) in 2012 (Sindh)
1 2 3 4 5 6 7 8
No. of slides Positive in
2012
(OPD)
(2012)
Total
OPD rred
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
Refe No. of Pt's
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. 13 9 4 5 7 6 6 6 6 6 of HF Jan 16580 361 106 0 188 126 12 7 5 0 Feb 16924 335 125 0 140 142 13 4 9 0 Mar 20595 463 177 0 221 180 5 1 4 0 Apr 14749 359 118 0 165 89 2 0 2 0 May 17799 573 292 0 356 257 24 6 18 0 Jun 19775 623 248 0 359 302 8 7 5 0 Jul 21014 840 414 0 413 221 13 4 9 0 Aug 17858 550 151 0 281 248 11 0 11 0 Sep 21687 1060 333 0 478 613 34 22 11 1 Oct 21325 756 158 0 471 296 44 31 12 1 Nov 19679 757 223 0 336 566 112 51 38 23 Dec 20061 639 279 0 266 404 40 26 6 8
Table 120: Malaria situation (RDTs ) in 2013 (Sindh)
1 2 3 4 5 6 7 8
No. of slides Positive in
2012
12)
(OPD)
(20
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
No. No. of Pt's
Referred
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. 13 12 11 12 11 12 of HF Jan 22855 646 459 0 234 510 60 15 22 23 Feb 22671 883 594 0 174 756 56 19 26 11 Mar 22487 894 565 0 76 855 35 12 21 2 Apr 18282 656 365 0 164 613 112 12 81 19 May 18550 807 532 0 266 791 235 7 201 27 Jun 20956 843 599 0 284 840 235 7 213 15 Jul 20990 1078 764 0 357 1039 230 7 214 9 Aug 19282 1219 877 0 307 1125 254 14 186 45 Sep 19528 1240 942 0 333 1212 237 25 162 50 Oct 9526 571 180 0 92 563 60 9 33 18
156
Table 121: Malaria situation (RDTs) in 2012 (Balochistan)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
ses
(2012)
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
No. No. of Pt's
Referred
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariaca
(FM2or DHIS) Malariacases No. of 17 16 14 5 7 14 8 6 4 2 HF Jan 6304 1689 1263 5 810 1259 183 175 4 4 Feb 5516 1058 853 2 112 846 62 57 3 2 Mar 6115 1537 1129 5 360 1104 124 109 4 11 Apr 5956 1258 935 6 199 788 64 54 6 4 May 6161 1943 1692 6 388 1640 310 306 3 1 Jun 5651 1979 1489 21 179 1379 145 127 11 3 Jul 5933 1620 1128 10 283 1086 160 92 66 2 Aug 5414 1853 1418 1 136 1380 98 89 9 0 Sep 9701 1724 1431 2 166 1349 95 87 5 4 Oct 6476 2521 1781 71 492 762 151 131 18 2 Nov 2477 1126 888 3 109 791 24 14 4 6 Dec 2655 710 438 0 71 320 14 7 5 2
Table 122: Malaria situation (RDTs ) in 2013 (Balochistan)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
ia
(2012)
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
No. No. of Pt's
Referred
Anti Anti Malar
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. of HF 23 23 19 4 12 19 Jan 9052 1524 966 2 209 1152 111 44 60 7 Feb 7428 1759 1017 5 101 1395 42 17 19 6 Mar 8330 1903 1429 1 84 1496 46 12 30 4 Apr 9337 1935 1196 4 305 1233 104 39 57 8 May 9779 2513 1948 6 458 2096 230 118 89 23 Jun 9807 2108 1773 5 513 2199 258 103 112 43 Jul 10766 2044 1788 4 430 2045 171 60 100 11 Aug 9904 2324 1380 1 409 1909 187 75 97 15 Sep 7230 1385 977 7 240 1345 117 39 73 5 Oct 2004 391 370 0 76 611 66 20 29 17
157
Table 123: Malaria situation (RDTs ) in 2012 (KPK)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
(2012)
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
No. No. of Pt's
Referred
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. 1 1 1 1 1 1 of HF Jan Feb 1800 4 4 0 0 4 0 Mar 2311 4 4 0 0 4 0 Apr 2086 9 9 0 0 9 0 May 2632 8 8 0 0 8 0 Jun 2091 7 7 0 0 7 0 Jul 2502 4 4 0 0 4 0 Aug 2425 7 7 0 0 7 0 Sep 2442 12 12 0 0 12 1 0 0 1 Oct 2567 16 16 0 0 16 2 1 0 1
Table 124: Malaria situation (RDTs ) in 2013 (KPK)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
IS)
(OPD)
(2012)
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
No. No. of Pt's
Referred
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DH
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. 5 5 5 5 5 5 of HF Jan 2200 12 12 0 1 12 1 0 1 0 Feb 5115 86 86 0 26 86 26 4 22 0 Mar 5550 111 111 0 15 111 15 0 14 1 Apr 6090 147 147 0 18 147 18 0 18 0 May 5461 182 182 0 44 182 44 1 40 3 Jun 6383 306 306 0 82 306 82 0 81 1 Jul 6497 282 282 0 74 282 74 0 73 1 Aug 5083 410 410 0 122 410 122 1 112 9 Sep 7438 467 467 0 164 467 164 10 132 22 Oct 5870 333 333 0 129 333 130 5 112 13
158
Table 125: Malaria situation (RDTs ) in 2012 (FATA)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
(2012)
Total
OPD
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
ria cases ria
No. No. of Pt's
Referred
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2or DHIS)
Complicated
Prepared
Malariacases
(FM2or DHIS) Mala No. 1 1 1 1 1 of HF Jan Feb Mar Apr 105 105 0 2 105 2 2 0 0 May 110 110 0 0 110 0 0 0 0 Jun 72 72 0 2 72 2 2 0 0 Jul 43 43 0 0 43 0 0 0 0 Aug 245 125 125 0 100 20 105 5 95 5 Sep 260 125 125 0 105 5 120 10 100 10 Oct 240 130 130 0 110 0 130 15 110 5 Nov 20 20 0 0 20 0 0 0 0 Dec 78 78 0 3 78 3 0 3 0
Table 126: Malaria situation (RDTs ) in 2013 (FATA)
1 2 3 4 5 6 7 8
No. of slides Positive
in 2012
(OPD)
(2012)
Total
OPD DHIS) or
No. No. of No. of
Months PF PV Mixed
No. No. of
Received
Total
Suspected Suspected
Treatment
No. No. of Pt's
Referred
Anti Anti Malaria
No. No. of slides
Positive
Malariacases
(FM2or DHIS)
(FM2or DHIS) (FM2
Complicated
Prepared
Malariacases
(FM2or DHIS) Malariacases No. 5 5 5 5 5 5 of HF Jan 476 128 128 0 6 128 6 0 6 0 Feb 665 111 111 0 3 111 3 0 3 0 Mar 627 199 199 0 2 199 2 0 2 0 Apr 581 241 241 0 8 241 8 0 8 0 May 599 185 185 0 17 185 17 1 15 1 Jun 693 196 196 0 19 196 19 0 16 3 Jul 979 322 322 0 25 322 25 5 20 0 Aug 1379 411 411 0 90 271 166 10 154 2 Sep 1746 326 326 0 95 215 145 5 137 3 Oct 1605 315 315 0 58 221 117 6 109 2
159
160
11. APPENDIX-B: SURVEY TEAMS
MONITORING TEAMS 1. Dr Huma Qureshi, Executive Director, Pakistan Medical Research Council
2. Dr Muhammad Arif Munir, Principal Research Officer, Pakistan Medical Research Council
3. Mehmood Ahmed, Survey Coordinator, Pakistan Medical Research Council
4. Mr. Naeem Durrani, Merlin
5. Dr. Ali Asghar Save the Children
6. Dr. Qutbuddin Kakar, WHO, Islamabad
7. Dr Abdul Majeed Jaffar, Senior Project Officer, Directorate of Malaria Control
8. Dr. Saba Farooqi, Manager Monitoring Unit, Directorate of Malaria Control
9. M&E Officer Sindh
10. M&E officers Balochistan
11. M&E Officers KPK and FATA
12. District M&E Officers (GF)
PROVINCIAL COORDINATORS
1. Dr Muhammad Hussan- Khyber Pakhtunkhwa and FATA 2. Dr Muhammad Ayaz Mustafa – Sindh 3. Mr. Munir Ahmed Khan Lodhi - Balochistan (Round 10 districts) 4. Sardar Muhammad Khan Durrani - Balochistan (Round-7 districts)
161
DATA ENTRY TEAM 1. Mr. Rizwanullah, Statistical Officer/Team Supervisor
2. Mr. Ilyas Qaiser
3. Mr. Warryal Dehri
4. Mr. Saeed Ahmad Shahid
5. Mr. Khalid Mehmood
6. Hafiz Saqib
7. Sajid Hussain
8. Mr. Sagheer Ahmad Khan
9. Mr. Zulfiqar Ahmad
162
FIELD TEAMS BALOCHISTAN
Team # 01 Dr. AsadUllah District Coordinator Mr. Amir Aziz Mr. Khan Muhammad Ms.Samina Bibi
Team #02 Dr. Dad Muhammad District Coordinator Mr. Amir Aziz Mr. Baz Muhammad Ms. Raheela Bibi
Team #03 Dr. Abid District Coordinator Mr. Abdul Wahid Mr. Abdul Quddous Ms. Nak Bakht
Team # 04 Dr. InyatUllah District Coordinator Mr. Khalil urRehman Mr. Shafi Muhammad Ms. Sakina Bibi
Team # 05 Dr. Shar Muhammad District Coordinator Mr.Khalil ur Rehman Mr. Mumtaz Ahmed Ms. Gul Nigar
Team # 06 Dr. Shabeer District Coordinator Mr. Sulman Mr. Muslim Ms. Rozina Hayat
Team # 07 Dr. Muhammad Qadeer District Coordinator Mr. Aftab Ullah Ms. Rahila Faiz
Team # 08 Dr. Marjan Khan District Coordinator Mr. Zafar Ali Khan. Mr. Abdul Rehman Ms. Bibi Zardana.
Team # 09 Dr. Shah Muhammad District Coordinator Mr. Aftikhar Khan Mr. Nasir Khan Mandokhail
163
Ms. Kiran Batool Team # 10 Dr. Khalil Tareen District Coordinator Mr. Muhammad Asif Mr. Muhammad Iqbal Ms. Gul Sima
Team # 11 Dr. Zafar Mangel District Coordinator Mr. Obaid Ullah Mr. Jan Muhammad Ms. Shgufta Gul
Team # 12 Dr. Sajjad District Coordinator Mr. Mehar Ullah Mr. Jameel Ahmed Ms. Anita Jalil Baloch Ms. Anila Baloch
Team # 13 Dr. Abdull Hameed District Coordinator Mr. Khuda Bux Mr. Abid Ali Mr. Gul Samin Ms. Rahat Noor
Team # 14 Dr. Essa Khan Jogizai District Coordinator Mr. Younis khajjak Mr. Shahbaz Barozai Ms. Rahbia Rehman
Team # 15 Dr. Kaleem Ullah District Coordinator Mr. Allah Bux Mr. Faheem Khan Ms. Fairy Gul Naz
Microscopy Team (Balochistan)
Mr. NajeebUllah Mr. Nisar Ahmed
164
FIELD TEAMS SINDH
Team # 01 Dr. A. Ghaffar Pirzada District Coordinator Ms. Munawar Begum Soomro Mr. Nasrullah Gilal Ms. Tehmina Mr. Inam Shah
Team # 02 Dr. A.K. Jamali District Coordinator Mr. Ali raza memon Ms. Shahnaz Soomro Mr.Asad Ali Mr. Hasan Ansari
Team # 03 Dr. Bherulal District Coordinator Mr. Gulab Ms. Saraswati Mr. Alji Mr. Karim
Team # 04 Dr. Suresh District Coordinator Mr. Abdul Wahid Ms. Aysha Bibi Ms. Shaista Mr. Anees Mr. Sultan
Team # 05 Dr. Anita Rathore District Coordinator Mr. Abdul Aziz Ms Afsheen Mr. Zafar Mr. Ahmed Mr. Muhammad Khalid
Team # 06 Dr. Abdul Kareem District Coordinator Ms. Shaista A. Ali Muhammad Zafar Ms. Fouzia Mr. Afaque
Microscopy Team (Sindh) Mr Ismail Brohi Mr. Muhammad Sultan Mr. Muhammad Khalid
165
FIELD TEAMS KPK/FATA
Team # 01 Mr. Irshad Ali District Coordinator Mr. Mohammad Shabir Mr. Said Mohammad Mr. Munir Khan Mr. Amir Bacha Miss Sumbul Miss Naila Bibi
Team # 02 Mr. Naseem Khan District Coordinator Mr. Imdad UlHaq Mr. Sajjad Ahmad Mr. Hayat Ullah Mr. Kaleem Ullah Miss Neelam Miss Salma
Team # 03 Mr. Mehboob Ali District Coordinator Mr. Sifayat Ullah Mr. Muhammad Shabbir Mr. Siar Mr. Muhammad Hayat Miss SaminaBibi Miss KulsoomBibi
Team # 04 Mr. Naseem Khan District Coordinator Mr. Anwar Shamim Mr. Alauddin Mr. Muhammad Abbas Mr. Taj Muhammad Miss Hameeda Gul Miss Shama
Team # 05 Mr. Naeem Sherpao District Coordinator Mr. Abdullah Mr. Roshan Gul Mr. Rehman Ullah Mr. Rahat Ullah Miss Farkhanda (LHV) Miss Farzana (LHV)
166
Team # 06 Mr Naeem Sherpao District Coordinator Mr. Shabbir Ali Mr. Aslam Khan Mr. Altaf ur Rehman Mr. Shareef Ullah Miss Hameeda Gul Miss Shama
Team # 07 Mr. Irshad Ali District Coordinator Mr. Burhan Ullah Mr. Mashki Alam Mr. Javed Khan Mr. Ishtiaq Ahmad Miss Sadia Miss HumeraSadaf Team # 08 Mr. Mohammad Hanif District Coordinator Mr. Ameer Badshah Mr. Nisar Ahmad Mr. Maqbool Ahmad Mr. Farooq Khan Miss SaminaNaheed Miss Noreen Abbas
Team # 09 Mr. Irshad Ali District Coordinator Mr. Noor Din Mr. Mustafa Khan Mr. Waqar Ali Mr. Muhammad Aslam Miss Shagufta Miss Riffat
Team # 10 Mr. Naseem Khan District Coordinator Mr. Said Nawaz Mr. Waseem Ullah Mr. Janas Khan Mr. Gul Nawaz Miss Sadia Bibi Miss Bushra
Team # 11 Mr. Irshad Ali District Coordinator Mr. Niamat Shah Mr. Rasheed Khan Mr. Muhammad Khan Mr. Mujahid Rehman Miss Razia Miss Kulsoom
167
Team # 12 Mr. Naseem Khan District Coordinator Mr. Muhammad Imran Mr. Muslim Gul Mr. Matloob Khan Mr. Niamat Ali Miss Poonum Naz Miss Sidra Batool
Team # 13 Mr. Mehboob Ali District Coordinator Mr. Murtaza Mr. Arif Mr. Ameer Jan Mr. Rahmat Ullah Miss Samina Naheed Miss Noreen Abbas
Microscopy Team (KPK & FATA)
Mr. Islam Badar Mr. Muiz Khan Mr. Abdur Razaq Mr. Shah Nawaz Mr. Anwar Khan Mr. Anwar Iqbal Mr. Haneef Khan Mr. Muhammad Farooq Mr. Shahid Mr. Mohammad Hanif Mr. Mohammad Jamil
168
12. APPENDIX-C: PHOTOGRAPHS OF THE SURVEY ACTIVITIES. TRAINING OF MASTER TRAINERS
169
TRAINING OF FIELD TEAMS
170
NUMBERING OF HOUSEHOLDS
171
PROFORMA FILLING
172
173
SLIDE PREPARATION AND MICROSCOPY
174
175
RAPID DIAGNOSTI TESTS (RDTs)
176
MONITORING OF FIELD TEAMS
177
178
VERIFICATION OF LLINS
179
13.
180
13. APPENDIX-D: QUESTIONNAIRES
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
Pakistan Medical Research Council Shahrah-e-Jamhuriat, Sector G-5/2, Islamabad 051-9217146, 9206092, 9207386, Fax: 051-9216774 E-mail: [email protected], Website: www.pmrc.org.pk
198