Y i ii 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 iii Title: Malaria Indicator Survey in 38 High Risk Districts of Pakistan- 2013-14 Institution: Pakistan Medical Research Council Year of Publication: 2014 iv v 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 vi vii 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 viii 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 ix 10.8.2. Source of LLINs received ...........................................................................