Thursday, June 28, 2012

The AMICS 2010/11 has been released. The MICS provides up-to-date information on the situation of children and women, and measures key indicators to monitor progress towards the Millennium Development Goals (MDGs).

To download the report, please visit:

Sunday, June 24, 2012

10. Detection of mixed Plasmodium falciparum & P. vivax infections by nested-PCR in Pakistan, Iran & Afghanistan

Sedigheh Zakeri, Qutbuddin Kakar, Faezeh Ghasemi, Ahmad Raeisi, Waqar Butt, Najibullah Safi, Mandana Afsharpad, Muhammad Suleiman Memon, Saber Gholizadeh, Masoud Salehi, Hoda Atta, Ghasem Zamani & Navid Dinparast Djadid


Background & objectives: Species identification and information on transmission pattern of malaria parasite in any malaria endemic area is key to success for a malaria control programme. In this investigation, malaria diagnosis using molecular method was used to assess the transmission pattern of malaria parasite in three malaria endemic regions: Afghanistan, Iran and Pakistan.

Methods: Blood samples were collected from the patients presenting with vivax malaria from Afghanistan (n = 108), Iran (n = 200) and Pakistan (n = 199). Malaria parasite detection was made by the gold standard (microscopy) and also nested-PCR assay, using 18S small sub-unit ribosomal RNA (ssrRNA) gene.

Results: Based on microscopy method, the level of mixed infection was zero to 2.5 per cent; however, nested-PCR assay detected 6.5, 22 and 23.5 per cent mixed infections in samples collected from Afghanistan, Iran and Pakistan, respectively. The present results showed that the co-infection of P. vivax with P. falciparum was frequent in malaria endemic regions of Iran and Pakistan.

Interpretation & conclusion: The present data suggest the need for improving microscopy diagnosis method and the clinician should also have careful clinical observation, along with the reports on Giemsa-stained thick blood films, particularly in summer time when P. vivax is predominant. Also sharing information on transmission pattern of mixed infection among these countries may help in designing better control strategies for malaria.

9. Genetic structure of Plasmodium vivax isolates from two malaria endemic areas in Afghanistan

Sedigheh Zakeri, Najibullah Safi, Mandana Afsharpad, Waqar Butt, Faezeh Ghasemi, Akram Abouie Mehrizia, Hoda Attad, Ghasem Zamanid, Navid Dinparast Djadid


In this study, the nature and extent of genetic diversity of Plasmodium vivax populations circulating in Afghanistan have been investigated by analyzing three genetic markers: csp, msp-1, and msp-3˛. Blood samples (n = 202) were collected from patients presenting with vivax malaria from south-western (Herat) and south-eastern (Nangarhar) parts of Afghanistan, and analysed using nested-PCR/RFLP and sequencing methods. Genotyping pvmsp-1 revealed type 1, type 2 and recombinant type 3 allelic variants, with type 1 predominant in parasites in both study areas. The sequence analysis of 57 P. vivax isolates identified a total of 26 distinct alleles. Genotyping pvcsp gene showed that VK210 type (86.6%) is predominant in Afghanistan. Moreover, three major types of the pvmsp-3˛ locus: type A, type B and type C were distinguished among Afghani isolates. The predominant fragments among Nangarhar and Herat parasites were type A (70.8% and 67.9%, respectively). PCR/RFLP products with Hha I and Alu I were detected 52 and 38 distinct variants among Nangarhar and Herat isolates, respectively. These results strongly indicate that the P. vivax populations in Afghanistan are highly diverse.


N. Safi, F. Adimi, R. P. Soebiyanto, R. K. Kiang

Commission VIII, WG 2

KEY WORDS: Malaria, risk prediction, Afghanistan, remote sensing


Malaria causes more than one million deaths every year worldwide, with most of the mortality in Sub-Saharan Africa. It is also a significant public health concern in Afghanistan, with approximately 60% of the population, or nearly 14 million people, living in a malaria-endemic area. Malaria transmission has been shown to be dependent on a number of environmental and meteorological variables. For countries in the tropics and the subtropics, rainfall is normally the most important variable, except for regions with high altitude where temperature may also be important. Afghanistan’s diverse landscape contributes to the heterogeneous malaria distribution. Understanding the environmental effects on malaria transmission is essential to the effective control of malaria in Afghanistan. Provincial malaria data gathered by Health Posts in 23 provinces during 2004-2007 are used in this study. Remotely sensed geophysical parameters, including precipitation from TRMM, and surface temperature and vegetation index from MODIS are used to derive the empirical relationship between malaria cases and these geophysical parameters. Both neural network methods and regression analyses are used to examine the environmental dependency of malaria transmission. And the trained models are used for predicting future transmission. While neural network methods are intrinsically more adaptive for nonlinear relationship, the regression approach lends itself in providing statistical significance measures. Our results indicate that NDVI is the strongest predictor. This reflects the role of irrigation, instead of precipitation, in Afghanistan for agricultural production. The second
strongest prediction is surface temperature. Precipitation is not shown as a significant predictor, contrary to other malarious countries in the tropics or subtropics. With the regression approach, the malaria time series are modelled well, with average R2 of 0.845. For cumulative 6-month prediction of malaria cases, the average provincial accuracy reaches 91%. The developed predictive and early warning capabilities support the Third Strategic Approach of the WHO EMRO Malaria Control and Elimination Plan.

7. Molecular surveillance of Plasmodium vivax dhfr and dhps mutations in isolates from Afghanistan

Sedigheh Zakeri, Mandana Afsharpad, Faezeh Ghasemi, Ahmad Raeisi, Najibullah Safi, Waqar Butt, Hoda Atta, Navid D Djadid


Background: Analysis of dihydrofolate reductase (dhfr) and dihydropteroate synthase (dhps) mutations in Plasmodium vivax wild isolates has been considered to be a valuable molecular approach for mapping resistance to sulphadoxine-pyrimethamine (SP). The present study investigates the frequency of SNPs-haplotypes in the dhfr and dhps genes in P. vivax clinical isolates circulating in two malaria endemic areas in Afghanistan.

Methods: P. vivax clinical isolates (n = 171) were collected in two different malaria endemic regions in north-west (Herat) and east (Nangarhar) Afghanistan in 2008. All collected isolates were analysed for SNP-haplotypes at positions 13, 33, 57, 58, 61, 117 and 173 of the pvdhfr and 383 and 553 of the pvdhps genes using PCR-RFLP methods.

Results: All 171 examined isolates were found to carry wild-type amino acids at positions 13, 33, 57, 61 and 173, while 58R and 117N mutations were detected among 4.1% and 12.3% of Afghan isolates, respectively. Based on the size polymorphism of pvdhfr genes at repeat region, type B was the most prevalent variant among Herat (86%) and Nangarhar (88.4%) isolates. Mixed genotype infections (type A/B and A/B/C) were detected in only 2.3% (2/86) of Herat and 1.2% (1/86) of Nangarhar isolates, respectively. The combination of pvdhfr and pvdhps haplotypes among all 171 samples demonstrated six distinct haplotypes. The two most prevalent haplotypes among all examined samples were wild-type (86%) and single mutant haplotype I13P33F57S58T61N 117I173/A383A553 (6.4%). Double (I13P33S57R58T61N117I173/A383A553) and triple mutant haplotypes (I13P33S57R 58T61N117I173/G383A553) were found in 1.7% and 1.2% of Afghan isolates, respectively. This triple mutant haplotype was only detected in isolates from Herat, but in none of the Nangarhar isolates.

Conclusion: The present study shows a limited polymorphism in pvdhfr from Afghan isolates and provides important basic information to establish an epidemiological map of drug-resistant vivax malaria, and updating guidelines for anti-malarial policy in Afghanistan. The continuous usage of SP as first-line anti-malarial drug in Afghanistan might increase the risk of mutations in the dhfr and dhps genes in both P. vivax and Plasmodium falciparum isolates, which may lead to a complete SP resistance in the near future in this region. Therefore, continuous surveillance of P. vivax and P. falciparum molecular markers are needed to monitor the development of resistance to SP in the region.

6. Field trial of three different Plasmodium vivax detecting rapid diagnostic tests with and without evaporative cool box storage in Afghanistan

Amy FW Mikhail, Toby J Leslie, Mohammad I Mayan, Rohullah Zekria, Nader Mohammad,
Mohammad A Hasanzai, Najibullah Safi, Christopher JM Whitty and Mark Rowland


Background: Accurate parasitological diagnosis of malaria is essential for targeting treatment where more than one species coexist. In this study, three rapid diagnostic tests (RDTs) (AccessBio CareStart (CSPfPan), CareStart PfPv (CSPfPv) and Standard Diagnostics Bioline (SDBPfPv)) were evaluated for their ability to detect natural Plasmodium vivax infections in a basic clinic setting. The potential for locally made evaporative cooling boxes (ECB) to protect the tests from heat damage in high summer temperatures was also investigated.

Methods: Venous blood was drawn from P. vivax positive patients in Jalalabad, Afghanistan and tested against a panel of six RDTs. The panel comprised two of each test type; one group was stored at room temperature and the other in an ECB. RDT results were evaluated against a consensus gold standard based on two double-read reference slides and PCR. The sensitivity, specificity and a measure of global performance for each test were determined and stratified by parasitaemia level and storage condition.

Results: In total, 306 patients were recruited, of which 284 were positive for P. vivax, one for Plasmodium malariae and none for Plasmodium falciparum; 21 were negative. All three RDTs were specific for malaria. The sensitivity and global performance index for each test were as follows: CSPfPan [98.6%, 95.1%], CSPfPv [91.9%, 90.5%] and SDBPfPv [96.5%, 82.9%], respectively. CSPfPv was 16% less sensitive to a parasitaemia below 5,000/μL. Room temperature storage of SDBPfPv led to a high proportion of invalid results (17%), which reduced to 10% in the ECB. Throughout the testing period, the ECB maintained ~8°C reduction over ambient temperatures and never exceeded 30°C.

Conclusions: Of the three RDTs, the CSPfPan test was the most consistent and reliable, rendering it appropriate for this P. vivax predominant region. The CSPfPv test proved unsuitable owing to its reduced sensitivity at a parasitaemia below 5,000/μL (affecting 43% of study samples). Although the SDBPfPv device was more sensitive than the CSPfPv test, its invalid rate was unacceptably high. ECB storage reduced the proportion of invalid results for the SDBPfPv test, but surprisingly had no impact on RDT sensitivity at low parasitaemia.

Tuesday, June 19, 2012

5. Therapeutic efficacy of Anti-malarial drugs in the treatment of uncomplicated malaria in Afghanistan, 2004-2007

Najibullah Safi, Awab Ghulam Rahim, Kamal Mustafa, Waqar Butt, Abdul Wasi Jawad, Tajwar Naseri, Rahmatullah


Routine anti-malarial drud resistant testing was conducted in three Malaria Reference Centers in Afghanistan using a standard WHO in vivo study design. Patients with confirmed uncomplicated P. falciparum were treated with sulfadoxin-pyrimethamin (SP) + Artesunate and followed for 28 day. Patients with P. vivax infection were treated with chloroquine (CQ) at standard dosage and followed for 28 days. All drugs tested showed greater than 95% efficacy, with SP+AS showing 100% acceptable clinical and parasitological response against P. falciparum and CQ showed 100% acceptable clinical and parasitological response against P. vivax. 

 Afghanistan Annual Malaria Journal (2009) P 50-53

4. Toward malaria risk prediction in Afghanistan using remote sensing

Farida Adimi, Radina P Soebiyanto, Najibullah Safi and Richard Kiang


Background: Malaria is a significant public health concern in Afghanistan. Currently, approximately 60% of the population, or nearly 14 million people, live in a malaria-endemic area. Afghanistan's diverse landscape and terrain contributes to the heterogeneous malaria prevalence across the country. Understanding the role of environmental variables on malaria transmission can further the effort for malaria control programme.

Methods: Provincial malaria epidemiological data (2004-2007) collected by the health posts in 23 provinces were used in conjunction with space-borne observations from NASA satellites. Specifically, the environmental variables, including precipitation, temperature and vegetation index measured by the Tropical Rainfall Measuring Mission and the Moderate Resolution Imaging Spectoradiometer, were used. Regression techniques were employed to model malaria cases as a function of environmental predictors. The resulting model was used for predicting malaria risks in Afghanistan. The entire time series except the last 6 months is used for training, and the last 6-month data is used for prediction and validation.

Results: Vegetation index, in general, is the strongest predictor, reflecting the fact that irrigation is the main factor that promotes malaria transmission in Afghanistan. Surface temperature is the second strongest predictor. Precipitation is not shown as a significant predictor, as it may not directly lead to higher larval population. Autoregressiveness of the malaria epidemiological data is apparent from the analysis. The malaria time series are modelled well, with provincial average R2 of 0.845. Although the R2 for prediction has larger variation, the total 6-month cases prediction is only 8.9% higher than the actual cases.

Conclusions: The provincial monthly malaria cases can be modelled and predicted using satellite-measured environmental parameters with reasonable accuracy. The Third Strategic Approach of the WHO EMRO Malaria Control and Elimination Plan is aimed to develop a cost-effective surveillance system that includes forecasting, early warning and detection. The predictive and early warning capabilities shown in this paper support this strategy.

Malaria Journal 2010, 9:125

Tuesday, June 12, 2012

Thursday, June 7, 2012

3. Contracting of primary health care services in Pakistan: Is up-scaling a pragmatic thinking?

Babar Tasneem Shaikh, Fauziah Rabbani, Najibullah Safi, Zia Dawar


Quite often, public health care systems in developing countries are struggling because of incompetence and a lack of provider responsiveness to the needs of consumers. On the contrary, the private sector dominates the system of health provision. In recent years, contracting has been experimented as an approach to ensure delivery of comprehensive public health services in an efficient, effective, superior and fair manner and has generally thrived well. The state's healthcare system in Pakistan has suffered a lot, owing to structural fragmentation, resource scarcity, inefficiency and lack of functional specificity, gender insensitivity and inaccessibility. However, partnering with the private sector has shown some exceptional accomplishments. Though challenging but structural reforms, involving private health sector have become indispensable. The overall experience shows that up-scaling of such initiatives in the country would require lot of cautions to be taken by the government.

J Pak Med Assoc, Vol. 60, No. 5, May 2010

Wednesday, June 6, 2012

2. Evaluation of Thermotherapy for the Treatment of Cutaneous Leishmaniasis in Kabul, Afghanistan: A Randomized Controlled Trial

Najibullah Safi, MD; COL Gary D. Davis, MC USA (Ret.); Mohammed Nadir, MD; Hamida Hamid, MD; COL Leon L. Robert, Jr., MS USA∥; MAJ Alan J. Case, MS ARNG (Ret.) 

Anthroponotic cutaneous leishmaniasis (CL) is a common cause of ulcerative lesions and disfiguring scarring among children in Afghanistan. Most lesions occur on the face and are commonly caused by the trypanosome protozoan parasite Leishmania tropica, transmitted by the bite of an infected sandfly (Phlebotomus sergenti). This study compared the effectiveness of a single localized treatment with thermotherapy to 5 days of intralesional administration of Glucantime for the treatment of CL. Three hundred and eighty-two patients with CL were randomly assigned to the two treatment groups and followed for 6 months. The cure rate for the thermotherapy group was 82.5%, compared to 74% in the Glucantime group. The authors concluded that a single localized treatment with thermotherapy was more effective than 5 days of intralesional administration of Glucantime. Additionally, thermotherapy was more cost-effective, with fewer side effects, of shorter duration, and with better patient compliance than intralesional Glucantime. 

MILITARY MEDICINE, 177, 3:345, 2012
My Publications:

1. Contracting-out Primary Health Care Services in Afghanistan

Effects of Contracting-out of Basic Package of Health Services on Quality of Health Care and Patients' Satisfaction in Afghanistan


Various reforms have been applied worldwide in health systems, since 1940s. The most recent reforms in developing countries started in 1990s. The important ingredient of these reforms comprises of re-organization of health systems, user charges for public services, public-private partnership and contracting-out of health services. The MoPH of Afghanistan started to contract-out health services in 2003. This study tends to assess the effects of contracting-out of BPHS on quality of health care and patients’ satisfaction in Afghanistan. This study indicates the contracting-out of health services as a viable option for the MoPH to expand the health services and improve the quality of care. NGOs required lesser amount of grants for the provision of BPHS with better outcome. Decentralization nurtures, quality of care improved and patients feel satisfied. The MoPH should draw lessons from the study for wider implementation and improvement of quality of care.

ISBN 978-3-639-22752-9