J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 82 Original Article Malaria Situation in an Endemic Area, Southeastern Iran Sajjad Fekri 1, Hassan Vatandoost 2, Ali Daryanavard 3, Mehran Shahi 1, Reza Safari 3, Ahmad Raeisi 4, Abdiqani Sheikh Omar 5, Mohammad Sharif 6, Abdollah Azizi 7, Aref Ah- mad Ali 8, Aboud Nasser 9, Ibrahim Hasaballah 10, *Ahmad Ali Hanafi-Bojd 2 1Infectious and Tropical Diseases Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran 2Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 3Hormozgan Province Health Center, Bandar Abbas, Iran 4Malaria Control Program, CDC, Ministry of Health, Tehran, Iran 5Malaria Control Program, Somalia 6Malaria Control Program, Afghanistan 7Health Center, Zarrindasht, Iran 8Roll Back Malaria Program, Aden, Yemen 9Roll Back Malaria Program, Hadramaut, Yemen 10State Malaria Program Manager, North Kordofan, Sudan (Received 21 Oct 2012; accepted 30 Sep 2013) Abstract Background: Malaria is an endemic infectious disease in southeastern parts of Iran. Despite years of efforts and intervention programs against malaria, transmission still occurs in Jask County. Methods: The epidemiological perspective of malaria in Jask County was conducted by gathering data from Jask County health center, during 2006–2010. A knowledge, attitude and practice study was also carried out. Data analy- sis was conducted using SPSS ver. 11.5. Results: A total of 2875 malaria cases were recorded, with highest and lowest numbers in 2007 and 2010, respec- tively. The number of cases had a decreasing trend from 1022 cases in 2006 to 114 cases in 2010. The main causa- tive parasitic agent was Plasmodium vivax. Blood examination rate and slide positive rate were also decreased from 39.5% and 4.3% in 2006 to 15.6% and 1.4% in 2010, respectively. Most of people interviewed in the KAP study had a good knowledge about malaria transmission and symptoms but their use of the bed net for prevention was low (35%). Conclusion: Malaria incidence had significant reduction during the study years. The main reason for this may be due to changing environmental condition for Anopheline breeding and survival because of drought. Another reason may be integration of vector management by using long lasting insecticide treated bed nets, active case detection and treatment by implementation of mobile teams and increasing in financial sources of malaria control program. Knowledge, attitude and practice of people were good in malaria control and prevention, but needs to do more activ- ities for health education and awareness. Keywords: Malaria situation, Jask County, Iran Introduction More than half of the world's population in approximately 100 countries is exposed to malaria. According to figures provided by the World Health Organization (WHO 2011a), 36% of the global population live in areas where there is risk of malaria transmission, 7% reside in areas where malaria has never been under meaningful control, and 29% live in areas *Corresponding author: Dr Ahmad Ali Hanafi-Bojd, E-mail: aahanafibojd@tums.ac.ir http://jad.tums.ac.ir Published Online: December 18, 2013 J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 83 where malaria was once transmitted at low levels or not at all, but where significant trans- mission has been re-established. In Iran, the total population at risk of ma- laria is 2,714,648 (4% of the total popula- tion) mainly living in southeastern provinces, namely Sistan and Baluchistan, Kerman and Hormozgan (WHO 2011a). There are some studies in last decade focused on malaria sit- uation analysis (Hanafi-Bojd et al. 2010, Vatandoost et al. 2010, 2011), as well as epi- demiological features and community based studies in malarious areas of southern parts of Iran (Rakhshani et al. 2003, Salehi et al. 2010, Hanafi-Bojd et al. 2011a, Youssefi and Rahimi 2011, McKelvie et al. 2012, Zoghi et al. 2012). According to the national strategy plan for malaria control, in respect to malaria status the total country has been classified in four strata: 1. Areas where local transmission of malaria occurs such as areas in Sistan and Baluchistan, Hormozgan and south parts of Kerman, and occasionally some-areas in Ardebil, Bushehr, Fars and Khorassan-e-Razavi Provinces. 2. Areas where the imported cases are found and the potential risk of malaria transmission exists such as areas in Guilan, Mazandaran, and Golestan Provinces. 3. Areas where the imported cases are found, but there is no risk of malaria transmission such as Yazd, Kurdestan, and Hamedan Prov- inces. 4. Areas where no malaria case was reported during the last three years. It seems there was no such area in Iran. Malaria remains an important public health concern in Jask County, where transmission occurs regularly, and infected immigrants can play an important role as mobile reservoirs (Personal communication with health center authorities). Therefore it is important to do a situation analysis of the disease for planning the control activities in future. The aim of conducting a situational analysis is to sys- tematically understand the malaria epidemi- ology of an area in a very short space of time and the health status, system and resource available for controlling the disease (WHO 2011b). A successful planning for the County, needs to use of the information that is al- ready available and analyzing in such a way as to understand the problems. On the other hand, the main point of the beginning of the situational analysis is to collect the data from respective references such as, health network office, hospital, health centers, communities, meteorology department and others. These items are covered by international diploma courses on malaria planning and manage- ment, as a joint training course by WHO and Tehran University of Medical Sciences (Mesdaghinia et al. 2013). The general objective of this study was to facilitate the development of friendly-user implementation plan for Jask County to iden- tify malaria-relevant gaps with its possible solutions. Materials and Methods Study area Jask County (25° 64’ N, 57° 77’ E) is a sea port located in South-Eastern corner of Iran adjacent to the Oman Sea, with a sur- face area of 16063 km2 (Fig. 1). Total pop- ulation of the County is 50070 (74% are liv- ing in rural areas). There are scattered inhab- itants and their occupation is mainly fishing and trade. Data collection In this retrospective study, the needed da- ta for 2006–2010 were obtained from health center of Jask, published papers and reports, weather forecasting organization of the city and annual reports of Hormozgan official au- thorities. An excel databank was created and analysis was conducted using this software. A knowledge, attitude and practice (KAP) study was conducted to evaluate the knowledge, at- titude and practice of people who referred to http://jad.tums.ac.ir Published Online: December 18, 2013 J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 84 the urban health center of Touhid, about ma- laria using structured questionnaire and in- terviewing. Data analysis For this purpose SPSS ver. 11.5 was used and graphs were prepared by excel 2007. Results A total of 2875 malaria cases were rec- orded and treated during the study period (Fig. 2). Plasmodium vivax is the main ma- laria parasite (94.92%) in the County fol- lowed by P. falciparum (5.08%). Average of malaria morbidity in months of the years during the study period showed two peaks in May and November, respectively. The max- imum and minimum of Annual Parasitic In- dex (API) were observed in 2006 (22.1) and 2010 (2.1), respectively (Table 1). Most of cases were reported to be autochthonous dur- ing 2006–2009, while in 2010 the imported cases were higher. Blood Examination Rate (BER) has increased to 2007 and then col- lapsed, but Slide Positive Rate has a decreas- ing trend during the study period, although it shows a peak in 2008 (Table 1). Autochtho- nous cases of malaria have decreased during the study period, while the imported cases had an increasing trend (Table 1). Figure 2 shows the distribution of malaria cases based on rural districts of the Jask County during the study period. During April-May and October-Novem- ber the temperature is between 25–30 oC with a relative humidity of more than 60% (Fig. 3), the suitable climatic factors for mos- quito breeding and increasing longevity. Based on the unpublished reports of Jask health cen- ter, Anopheles stephensi and An. culicifacies seems to be the main vectors in the area. These species are active during the year due to favorite climatic conditions. There was no published entomological investigation in the Jask area for fauna, density, insecticide sus- ceptibility and parasitic infection of Ano- pheline mosquitoes. The health facilities and personnel of the County were included: one urban heath cen- ter, 6 rural health centers, one sub health cen- ter, 27 health houses, one hospital, 11 physi- cians, 6 public health officers and 49 health care workers (Behvarz). Furthermore, malaria control program has had a total of 25 mobile teams. Based on the national protocol, malaria control interventions in the area are includ- ing case detection and treatment, indoor re- sidual spraying by Deltamethrin WP 10% in rural area with 90% coverage, distributing Long Lasting Insecticide impregnated Nets (LLINs) in rural areas with 80% coverage, as well as larviciding. Data obtained from the Jask County health center shows high IRS coverage during the study period and dis- tribution of LLINs during 2009 and 2010. These vector control activities along with other measures such as good active case de- tection (Table 2) and increasing the financial resources of malaria control program for the study area are the main reasons for the de- cline of the disease. A total of 41 people (64.3% males, 35.7% females) participated in the KAP study, 96.4 % under 45 years old. The education level was categorized in four levels: illiterate (10.7%), primary school (32.1%), high school (25%), and university degree (32.1%). Among the respondents just 17.9% had a history of ma- laria infection. Most of the study population (82.1%) believed that mosquito bite is the transmission route of malaria and fever is the main symptom. When they asked about the role of insecticide treated bed net (ITNs) for prevention malaria, 67.9% answered yes, meanwhile 60.7% was agree that water stor- age utensils can increase the risk of malaria transmission. The attitude of respondent showed 28.6% and 39.3% were respectively agree and strongly agree with this fact that ITNs can prevent malaria transmission. These http://jad.tums.ac.ir Published Online: December 18, 2013 J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 85 rates about using insecticide were 50% and 17.9%, respectively. In practice, 78.6% stat- ed that they allow the spray men to spray their house, 96.4% will refer to the nearest health center as soon as their child feels fe- verish, but just 35.7% used ITNs during last year (Table 3). Fig. 1. Location of Jask County in Iran Fig. 2. Malaria distribution map, Jask County, 2006–2010 Table 1. Malaria indices in Jask County, Southeastern Iran, 2006–2010 Year Malaria indices No. Cases SPR API BER Autochthonous Imported P. vivax P. falciparum Total 2006 4.3 22.1 39.5 1000 22 1000 22 1022 2007 2.5 21.6 50.6 1013 12 954 70 1024 2008 3.5 10.6 28.1 485 27 495 11 506 2009 2 4.2 20.6 162 47 183 26 209 2010 1.4 2.2 15.6 34 80 97 17 114 SPR: Slide positive rate, API: Annual parasitic index, BER: Blood examination rate http://jad.tums.ac.ir Published Online: December 18, 2013 J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 86 Table 2. Activities of malaria control program in Jask County, Southeastern Iran, 2006–2010 Index Year 2006 2007 2008 2009 2010 Total No. of distributed LLINs 0 0 0 3560 2660 IRS coverage No data 95% 93.2% 93.8% 95% Active case detection 687 879 335 118 87 Mobil teams 25 25 25 25 25 Average of malaria cases in relation to climatologically parameters,Jask district, 2006-2010 0 20 40 60 80 100 120 Ja n Fe b M ar ch Ap ril M ay Ju ne Ju ly Au g Se p Oc t No v De c Month RH% Rai nfal l (mm) Temp (oC) Ave. Cas es Fig. 3. Average of malaria cases in relation to climatology parameters in Jask County, southeastern Iran, 2006–2010 Table 3. KAP study on malaria, Jask Country, 2011 Question Answer Frequency Percent Gender Female Male 10 18 35.7 64.3 Age 15-30 30-45 45< 17 10 1 60.7 35.7 3.6 Martial status Single Married Widow 9 18 1 32.1 64.3 3.6 Education level Illiterate Primary/secondary High school University 3 9 7 9 10.7 32.1 25 32.1 Job Employed Unemployed Retired 12 15 1 42.9 53.6 3.6 History of malaria infection Yes No 5 23 17.9 82.1 Transmission route Air Mosquito bite Food I don’t know 1 23 2 2 3.6 82.1 7.1 7.1 Malaria symptoms Fever Cough Other 23 4 1 82.1 14.3 3.6 Using insecticide treated bed nets can prevent us from getting Ma- laria True False I don’t know 19 6 3 67.9 21.4 10.7 http://jad.tums.ac.ir Published Online: December 18, 2013 J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 87 Storing water in utensils can increase the risk of malaria transmis- sion True False I don’t know 17 6 5 60.7 21.4 17.9 Using insecticide treated nets can prevent malaria transmission Strongly disagree Disagree Uncertain Agree Strongly agree 3 2 4 8 11 10.7 7.1 14.3 28.6 39.3 Applying Insecticide Residual Spray can prevent malaria transmis- sion Disagree Uncertain Agree Strongly agree 4 5 14 5 14.3 17.9 50 17.9 The price of insecticide treated nets is low Strongly disagree Disagree Uncertain Agree Strongly agree 1 3 12 11 1 3.6 10.7 42.9 39.3 3.6 Applying Insecticide Residual Spraying control malaria transmis- sion, cannot contaminate our house Strongly disagree Disagree Uncertain Agree Strongly agree 2 1 7 16 2 7.1 3.6 25 57.1 7.1 I allow the spray man to spray my home to prevent malaria trans- mission Yes No Don’t answer 22 3 3 78.6 10.7 10.7 If my child feels feverish, I bring him/her to the nearest health cen- ter Yes No 27 1 96.4 3.6 If I see a place with stagnant water around my house, I will prefer to Add oil Land filling or drainage leaving 5 19 4 17.9 67.9 14.3 I used ITN for prevention of malaria in the last 1year Yes No 10 18 35.7 64.3 Discussion Both P. vivax and P. falciparum are report- ed from the Jask County, although vivax ma- laria is dominant species. There is also report of malaria due to imported species P. malariae in Bandar Abbas, west of the study area, but this species in not common in Iran (Nateghpour et al. 2010b). Since drug resistance is report- ed from malaria parasites in Iran (Raeisi et al. 2006, Nateghpour et al. 2010a), it is suggest- ed to do such a survey in Jask County for better understanding the situation of malaria and planning control programs in the area. Although there is no published report on Anopheline mosquitoes of the study area, five malaria vectors including An. stephensi, An. culicifacies, An. dthali, An. superpictus and An. fluviatilis are reported to be active in Bashagard, adjacent to the north of Jask Coun- ty (Hanafi-Bojd et al. 2012a,b). Among these species, An. stephensi and An. culicifacies were collected during the entomological activities of Jask health center. These two species are reported as main malaria vectors of south and southeastern parts of Iran (Vatandoost et al. 2006, Hanafi-Bojd et al. 2011a,b). As it can be understood from the clima- tology chart (Fig. 3), the mosquito breeding can be done around the year, because of favora- ble condition. Therefore, a comprehensive en- tomological study on the fauna of Anopheline and their density during the year, their par- asitic infection and susceptibility status to WHO recommended insecticides/ larvicides is suggested and should be included in malaria vector control activities in the area. Regarding to our results, the knowledge, attitude and practice of the respondents was relatively good in malaria control and preven- tion, but needs to do more health education to improve their awareness. The relative good Table 3. Countinued… http://jad.tums.ac.ir Published Online: December 18, 2013 J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 88 level of knowledge may be due to living peo- ple in an endemic area for malaria. The same results were obtained by Hanafi-Bojd et al. (2011a) in Bashagard County, north of the study area. Some other studies reported an in- creasing trend in literacy can be a protective factor for malaria morbidity (Koram 1989, Masoumi et al. 2003). One-third of the re- spondents in a KAP study in Baluchistan area, east of the Jask County, considered ma- laria as an important disease in the area, and more than 58% of them considered mosqui- toes to be the cause of the malaria disease. So it can be concluded more contact with malar- ia rural areas resulted to more knowledge about the disease (Rakhshani et al. 2001). Constraints and challenges seems to be: massive population movement between Iran, Pakistan and Afghanistan, vector control chal- lenges at the County, inadequate skilled med- ical staff in malaria case management, weak inter-sectoral coordination for malaria con- trol especially in urban areas, low socio-eco- nomical status of those who live in the area. The most important immigrants in south- eastern part of the country are illegal and so they pass the unofficial borders, their exact number and infection to infectious diseases including malaria is unknown. But it is nec- essary to plan for detection of asymptomatic cases that may act as the reservoir of the dis- ease (Nateghpour et al. 2011, Turki et al. 2012). Priority areas for malaria control in the study area are: strengthening malaria surveil- lance system in the County, developing inte- grated vector management strategy, strength- ening vector control activities by larviciding at the County level, capacity buildings on prompt case detection and treatment in the immigrant population, supporting cross bor- der coordination with Afghanistan and Paki- stan, strengthening malaria early warning and early detection system and developing ma- laria epidemics preparedness plan based on a powerful database that should be established for the area. Therefore it is recommended to reinforce human capacity on malaria control activities at different levels of health per- sonnel, strengthen the existing vector manage- ment program at the County level, establish- ing a spatial malaria database for the County and training ArcGIS to the malaria experts of the County to handle the database, devel- oping and implementation a plan for malaria epidemics preparedness and response, build up malaria surveillance system with appro- priate epidemic thresholds in epidemic-prone settings, support operational research in the field of malaria entomology and parasitology as well as insecticide resistance. Conclusion Malaria incidence had significant reduc- tion during the study years. The main reason for this may be due to changing environmen- tal condition for Anopheline breeding and survival because of drought. Another reason may be integration of vector management by using long lasting insecticide treated bed nets, active case detection and treatment by implementation of mobile teams and increas- ing in financial sources of malaria control program. Knowledge, attitude and practice of people were good in malaria control and prevention, but needs to do more activities for health education and awareness. Acknowledgements The authors are grateful to the kind per- sonnel of the Jask County health center as well as Hormozgan Province Health Center authorities, for their collaboration during this study. This work is a part of field exercise in 13th International Diploma Course on Malar- ia Planning and Management that was held out by collaboration of World Health Organ- ization, Tehran University of Medical Sci- ences, Ministry of Health and National Insti- tute of Health Research (Bandar Abbas Sta- http://jad.tums.ac.ir Published Online: December 18, 2013 J Arthropod-Borne Dis, June 2014, 8(1): 82–90 S Fekri et al.: Malaria Situation in … 89 tion as WHO Regional Malaria Training Cen- tre) in 2011. The authors declare that there is no conflict of interest. References Hanafi-Bojd AA, Vatandoost H, Philip E, Stepanova E, Abdi AI, Safari R, Moh seni Gh, Bruhi MI, Peter A, Abdulrazag Sh, Mangal G (2010) Malaria situation analysis and stratification in Bandar Ab- bas County, Southern Iran, 2004–2008. Iran J Arthropod-Borne Dis. 4(1): 31–41. 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