11. Progress and Challenges to Malaria Control in Afghanistan
Najibullah Safi, Toby Leslie, Mark Rowland
Malaria in Afghanistan, as in most of South Asia, is the product of two coexistent species, Plasmodium falciparum and P. vivax. Transmission of disease is relatively low, and the predominant species is P. vivax, causing 80‐90% of cases. In the most endemic areas, incidence is estimated at 10‐100 per 1000 person years for vivax malaria and 1‐10 per 1000 person years for falciparum malaria.
Treatment for the two species differs because vivax remains susceptible to chloroquine, while falciparum malaria has developed unsupportable levels of resistance. Falciparum malaria, if confirmed is treated with the more expensive sulfadoxine‐pyrimethamine with artesunate (SP/AS). Malaria incidence is sufficiently low that the majority of cases suspected to have malaria by clinical evaluation are negative on blood examination (slide positivity rate is 15‐30% in most areas). In the absence of diagnosis, the present policy is to treat all suspected cases with SP and chloroquine. In many areas, diagnosis is unavailable or unreliable and therefore many patients are inappropriately treated. Delivery of diagnostics is therefore crucial. Delivery of personal protection is by insecticide treated nets, and there has been a rapid rise in coverage. Perhaps the biggest barrier to effective malaria treatment in this region, where vivax malaria predominates, is the absence of effective anti‐relapse therapy that can provide radical cure. Primaquine use is unavailable because of the presence of G6PD deficiency in the population.
There are numerous challenges to providing sufficient pressure on malaria to maintain control in South Asia, amongst the most important of which is the continued socio‐political instability in the region. If the goal of eradication or elimination of malaria is to be achieved, this prerequisite is required.
Afghanistan Annual Malaria Journal (2009) P 15-29