Irrational use of antimalarial drugs in rural areas of eastern Pakistan: a random field study

Abstract

BackgroundPrescription of antimalarial drugs in the absence of malarial disease is a common practice in countries where malaria is endemic. However, unwarranted use of such drugs can cause side effects in some people and is a financial drain on local economies. In this study, we surveyed the prevalence of malaria parasites in humans, and the prevalence of the malaria transmitting mosquito vectors in the study area. We also investigated the use of antimalarial drugs in the local people. We focused on randomly selected rural areas of eastern Pakistan where no malaria cases had been reported since May 2004.MethodsMass blood surveys, active case detection, passive case detection, and vector density surveys were carried out in selected areas of Sargodha district from September 2008 to August 2009. Data pertaining to the quantities and types of antimalarial drugs used in these areas were collected from health centers, pharmacies, and the district CDC program of the Health Department of the Government of the Punjab.ResultsSeven hundred and forty four blood samples were examined, resulting in a Blood Examination Rate (BER) of 3.18; microscopic analysis of blood smears showed that none of the samples were positive for malaria parasites. Investigation of the mosquito vector density in 43 living rooms (bedrooms or rooms used for sleeping), 23 stores, and 32 animal sheds, revealed no vectors capable of transmitting malaria in these locations. In contrast, the density of Culex mosquitoes was high. Substantial consumption of a variety of antimalarial tablets, syrups, capsules and injections costing around 1000 US$, was documented for the region.ConclusionUse of antimalarial drugs in the absence of malarial infection or the vectors that transmit the disease was common in the study area. Continuous use of such drugs, not only in Pakistan, but in other parts of the world, may lead to drug-induced side effects amongst users. Better training of health care professionals is needed to ensure accurate diagnoses of malaria and appropriate prescription of antimalarial drugs delivered to communities.

Prevalence and patterns of antifolate and chloroquine drug resistance markers in Plasmodium vivax across Pakistan

“…Chloroquine is no longer indicated for treatment of P. falciparum but is recommended in combination with primaquine for treatment of P. vivax . Although the nature of anti-malarial use in Pakistan is not well-characterized, the availability of SP and other drugs as monotherapy has been documented [48] and, along with misdiagnosis of mixed infections [49] and presumptive treatment [50], likely results in P. vivax infections being frequently treated with AS + SP or SP alone. This study sought to characterize the current distribution of chloroquine resistance-associated polymorphisms in pvmdr1 and SP resistance-associated point mutations in pvdhfr and pvdhps in Pakistan.…”

Prevalence of drug resistance associated mutations in Plasmodium vivax against sulphadoxine-pyrimethamine in southern Pakistan

“…Though recommended, implementation of treatment guidelines is non-existent with studies documenting only 1% of patients receiving combination therapies [2,5]. Furthermore, with co-existence of both species in significant proportions, issues of misdiagnosis due to sub-microscopic infections in association with P. falciparum [6] and inappropriate treatment with mono-therapies exist in the public sector [7]. The consequence of such approach may have implications on P. vivax control in the region since mono-therapy may induce drug pressure on P. vivax resistance associated genes and trigger the selection of resistant alleles.…”

Inappropriate prescribing of antimalarial therapy for the treatment of undifferentiated febrile illness among the elderly

“…Patients are usually treated based on their clinical symptoms, such as fever, chills, fatigue and myalgia . In some instances, all pyrexia of unknown origin, with or without the aforementioned symptoms, not responding to antibiotics is generally treated as malaria, even in the absence of a laboratory‐confirmed diagnosis . Bacterial and viral infections like sepsis, meningitis, typhoid, influenza and urinary tract infection, among others, have similar symptoms and cannot be distinguished from malaria without diagnostic testing .…”

“…and Phyo et al . Overdosage was seen in 41% cases, which can lead to unwanted adverse effects such as vomiting, nausea (quinine, mefloquine), fatigue, anorexia, dizziness, pulmonary toxicity (mefloquine), neuropsychiatric effects (mefloquine, chloroquine), effects on the retina, blindness (quinine) and neurotoxicity mainly targeting the auditory and vestibular pathway (artemisinin in combination with mefloquine) …”

“…11 In some instances, all pyrexia of unknown origin, with or without the aforementioned symptoms, not responding to antibiotics is generally treated as malaria, even in the absence of a laboratory-confirmed diagnosis. 12 Bacterial and viral infections like sepsis, meningitis, typhoid, influenza and urinary tract infection, among others, have similar symptoms and cannot be distinguished from malaria without diagnostic testing. 11 Wrong diagnosis and inappropriate treatment, including inappropriate choice of medications, inappropriate dose or inappropriate duration of treatment, can have several negative consequences.…”