Background : Malaria has become a critical world health problem in recent years. Several factors have been responsible for increasing its incidence, such as wide usage of insecticides and drug resistance. It still remains as a matter of concern in Iran. It is under control in all parts, except in three southeastern provinces. Aim: Khorasan Razavi is one of the Iranian provinces with a lot of immigrants each year. Therefore, epidemiological study of the malaria is necessary in non-endemic provinces. Materials and Methods: This research was a descriptive study to evaluate epidemiological status of the malaria in April 2001-March 2008 using all patients’ data from whole of the province. Results: Total recorded cases were 945 within 7 years. The highest incidence was observed in 2001 and the lowest in 2006. Plasmodium vivax was observed in 911 cases and 30 cases were positive for P. falciparum. Mixed species were seen in four cases. Malaria incidence had decreased since 2001. 34.6% of transmitted cases were local, 61% were transmitted from (other provinces) inside and outside the country, relapse cases formed 5.4% and transmitted routes of the rest of the cases were unknown. The highest incidence was observed in people of age 15 years and higher and mostly in men. Mashhad and Sarakhs cities had the highest incidence rate. Conclusion: Preventive efforts must be continually taken in spite of decreasing rate of the malaria.
Keywords: Epidemiology, Khorasan Razavi Province, malaria, P. falciparum, P. vivax
|How to cite this article:
Shafiei R, Mahmoodzadeh A, Hajia M, Sanati A, Shafiei F. Epidemiology of malaria in Khorasan Razavi Province, northeast of Iran, within 7 years (April 2001 – March 2008). Ann Trop Med Public Health 2011;4:12-7
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Shafiei R, Mahmoodzadeh A, Hajia M, Sanati A, Shafiei F. Epidemiology of malaria in Khorasan Razavi Province, northeast of Iran, within 7 years (April 2001 – March 2008). Ann Trop Med Public Health [serial online] 2011 [cited 2020 Aug 4];4:12-7. Available from: https://www.atmph.org/text.asp?2011/4/1/12/80515
Malaria is a preventable and curable and the most important parasitic disease in the world , About 40% of world population lives in malarious areas in underdeveloped countries. The control of this disease is one of the important socioeconomic factors for development of each country, as a lot of investment needs to be made for it. Malaria has been widely prevalent for a long time in Iran. The results of antimalaria campaign and malaria eradication program (MEP) up to 1973 caused almost elimination of malaria in the northern parts of Zagross Mountains, which were in the consolidation phase of MEP. In the southern parts of Zagross Mountains, the incidence of malaria cases considerably reduced, and the total annual malaria cases in Iran came down to 12,000 in 1973. However, these temporary relative successful results of MEP in Iran encouraged the health authorities to integrate MEO into Communicable Diseases Control (CDC). 
This integration caused reduction of MEP activities and resulted in elevation of malaria incidence. The objectives of antimalaria campaign were to decrease malaria transmission and infection rates in the residual foci in southern part of Iran and sustaining the northern parts free of malaria as far as possible. In 1980, the Ministry of Health, according to suggestions of Malaria National Scientific Committee and WHO malaria advisors, changed MEP to MCP (malaria control program).  Now, the most important malaria transmission areas, i.e. the problem areas, are in the southeast part of the country including Sistan and Baluchestan, Hormozghan Provinces, and southern part of Kerman Province with a combined population of approximately 3 million and are considered to be “refractory malaria regions”. Annual Parasite Incidence (API) was reported to be 8.74 per 1000 population. 
The present problems of MEP in the southern parts of Iran include plurality of malaria vectors and their various behaviors, resistance of the main vector “A. Stephensi” to some insecticides, long distances between some villages and lack of suitable transportation roads, structure of living houses, socioeconomic conditions, immigration from malarious neighboring countries and some other operational problems. 
Recently, a new threat of imported malaria has emerged from the northwestern part of the country, Parsabad area, which was affected by a serious epidemic of Plasmodium vivax.  Thus, it can transfer from the endemic parts to other parts because of the ecological and regional conditions and its reservoirs. According to the Deputy of Health, 24,241 microscopic slides (out of 1,358,262) were positive for malaria in 2003, containing 19% Plasmodium falciparum, 80% P. vivax and 1% mixed species. 90% of the positive cases were reported from south of Zagros and southeastern part of Iran. 
Malaria has lost its previously importance in other provinces, and its incidence has come down since 1991. It seems the major problems encountering the steps taken have been due to immigrants from Pakistan and Afghanistan.  Our objective was to design an epidemiological study of malaria in Khorasan Razavi Province, which sees rise in immigrants every year, to have appropriate health and treatment efforts.
Study design: This research was a descriptive case series study based on collecting data from rural and urban populations referred to health centers for malaria, from April 2001 to March 2008.  Active case finding was performed by checking suspected people at their house collecting blood smears, and inactive case finding was based on collecting smears from the patients having fever and chills, referred to health centers.
Blood samples were collected from all the individuals feeling feverish and belonging to immigrant population from endemic areas, especially those from Sistan and Baluchestan, Hormozghan and Kerman Provinces and the groups from Pakistan and Afghanistan.
Study area: Khorasan Province has recently been divided into three provinces: South, North and Razavi Provinces. Khorasan Razavi Province is vast with an area of 127,432 km 2 and with 20 cities and 3767 villages. It is bounded by the country of Turkmenistan in the north and north-east, Afghanistan in the east, Yazd, Semnan and North Khorasan Provinces in the west and South Khorasan Province in the south. Its vicinity to Afghanistan and Pakistan has previously caused an increased rate of the disease.
Samples and staining method
Peripheral blood smears were taken from all the persons who had fever. Slides were prepared in both thin film at one end and thick film at the other; only the thin portion was fixed; both parts of the film were stained with Giemsa’s stain simultaneously  and examined under microscope by 100Χ magnification.
Plasmodium species, epidemiology, date of the infection, transmitted route to the patients and relapse cases were determined. Positive results were entered in the study, after their confirmation in health center of the province.
Transmitted routes were categorized as local transmission based on the following criteria: those individuals who had not traveled recently, not received blood, and with no history of any previous infection, transmission from outside the country, transmission from the high-risk provinces. All data were analyzed by SPSS (version 14) and square test.
A total of 126,084 data were collected from 20 cities; of these, 945 cases were positive for malaria. P. vivax was detected in 911 cases and 30 cases were positive for P. falciparum. Mixed species was observed in four cases. Annual Parasite Incidence (API) had decreased from 10 in 2001-2002 to 0.48 in 2007-2008, and the highest positive rate was 494 in 2001-2002 and had reduced to 26 cases in 2007-2008 [Table 1]. 665 were males, while 4 cases of the remaining 280 were pregnant women.
||Table 1: Distribution frequency of parasite and epidemiological criteria in Khorasan Razavi Province (2001-2008).
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Highest positive rate of malaria was observed among students (26.1%), followed by workers (18.4%) and housekeepers and self-employment groups (17.4%). Male patients were at higher risk than female patients by nearly three times (70.4%) [Figure 1]. All patients were studied in four age groups and those of age above 15 years had the highest infection rate (72.4%). The youngest patient was a 28 day-old neonatal and the eldest one was a patient of 81 years of age [Table 2].
||Table 2: Age distribution frequency of malaria in Khorasan Razavi Province (2001-2008)
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||Figure 1: Prevalnce rate of malaria in Khorasan Razavi Province based on the patient’s job
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The highest positive rate was observed in Mashhad and Sarakhs cities [Table 3]. 315 positive cases (34.6%) were locally transmitted and they were mostly reported in 2001-2002 from Sarakhs city. 576 cases (61%) had their route of infection from outside the province, including abroad, high-risk provinces and other provinces. Of these, 418 were from abroad: 381 patients (40%) were immigrants from Afghanistan and Pakistan, 37 of the positive cases were those who returned to the country after acquiring infection from outside the country. The rest 158 positive cases were from other provinces including high-risk places. Relapse cases numbered 49 (5.4%) which were mostly observed in 2002-2003 in Sarakhs city. It was due to improper treatment of infected cases of Sarakhs city in 2001. We were not able to determine the transmission route in five cases [Table 4].
||Table 3: Distribution frequency of malaria based on parasite species in Khorasan Razavi
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||Table 4: Distribution frequency of malaria based on living area in Khorasan Razavi Province (2001- 2008).
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All cases infected with P. vivax suitably responded to Chloroquine. Those cases infected with P. falciparum were also treated with Chloroquine and Primaquine. Relapse was observed in 12 of these cases on treatment with Fansidar and Quinine. High incidence rate was observed in summer with 506 cases (53.5%), especially in the month of August during the study period (20.6%) [Table 5].
||Table 5: Distribution frequency of malaria during the 12 month of year in study period
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The most influential parameters on malaria are immunological and genetic characteristics of population at risk of infection, parasitic species, type of mosquito, rate of rainfall and humidity, distribution of mosquito feed areas, use of antimalarial drugs and other controlling equipments for reducing the risk of transmission. , The geographic and climatic conditions, irrigation facilities, environmental conditions, tribal and population movement, structure of living houses, lack of road transportation and greater distance among villages, illiteracy, economic and social problems, etc. are favorable for malaria transmission in Iran. 
Control and prevention of malaria faces serious problem because of parasitic resistance to some antimalarial drugs and mosquito resistance to some insecticides, as well as mosquito and parasite species.
Distribution of malaria depend upon socioeconomic parameters and availability of primarily welfare facilities such as house, road, electricity, health service and enough awareness on personal prevention. Therefore, these parameters play an important role in controlling malaria. At the present time, controlling malaria is facing a major problem because of the political situation of neighboring countries, especially Afghanistan, due to which several job-seeking people are immigrating to Iran.  Iran is among the countries located in the Eastern Mediterranean Region with low malaria endemicity, and in some of its areas, there is a risk of malaria transmission.  Malaria is the most important parasitic disease in Iran.
Malaria has been controlled in most parts of the country in previous decade but reappeared again because of drug-resistant parasites, immigrant population and people traveling especially to endemic areas. Thus, lot of steps need to taken.  One of the main problems in the control of malaria is resistance of P. falciparum to Chloroquine and some other antimalarial drugs, which is now more or less common in the malaria endemic areas in the world. 
Khorasan Razavi has religious visitors, sometimes about four times of its population. This caused an increase in the incidence of malaria cases. Malaria rate is 2.75 per 100,000 of population; 61% of these cases are Afghan immigrants and visitors. Local transmission of the disease is about 33%. Many observed cases are from infected family members of Afghan immigrant who were not properly treated in their own country. Another high-risk group the family members of those called into military services in Sistan and Baluchestan Province, especially in Chahbahar city; these people transferred type B variant of the disease to their family members after they came back from service.
This study showed P. vivax as having the highest rate, which is comparable to studies conducted in other parts of Iran. P. vivax was observed in 97.5% cases in a study performed in Baboulsar during 1996-1997.  In another study performed in Kermanshah, 8.5 per 100,000 reported during 1985-1996, with similar rates in males and females, with a mean age of 20 years. Ninety-eight percent of cases were positive for P. vivax at the Kermanshah study. 
Decreasing and increasing rates of this study were similar to that observed in a study performed in Esfahan Province.  A study reported from Altamim Province of Iraq indicated that the highest cases were infected locally and not due to immigration, in contrast to our results that had direct correlation to economic situation and performance of control program in the region. 
Decreasing and increasing rates of malaria have been observed in Nicaragua, which is one of the most infected countries in the Central America. High prevalence of malaria in this country was due to the war that distributed to non-war area.  Analyzed data revealed malaria had increasing and decreasing rates in Khorasan Razavi Province. Increasing rate in 2001-2002 and 2002-2003 was due to local transmission of the disease as well as immigration of Afghan people, but it decreased from 52.3% in 2001-2002 to 2.8% in 2007-2008 of all positive cases at the end of study. This is in agreement with a previously reported study. Total reported malaria cases in Iran reduced from 96,340 (with 45% P. falciparum) in 1991 to 18,966 (with 12% P. falciparum) in 2005. About 30-50% of malaria patients were among foreign immigrants.  Besides, local transmission was not observed from 2002-2003 because of ecological status of the region and presence of Anopheles superpictus. It underlines the importance of efforts to prevent the risk of malaria epidemic.
The most affected group of people was of age 15 years and above and many of them were male patients. Therefore, our concern should be on young males, that is the potentially working group. In accordance with other studies, the most prevalent time of the disease has been observed to be the warmer months due to an increase in the number of mosquitoes.
In the last study perfomed during 19821991 in east Azarbaijan Province, 184 out of total 444 locally observed malaria cases were reported from Moghan plateau.  In the meantime, Ataiyan reported just 44 of total 636 malaria cases to be Iranians from Zanjan Province and the rest of the infected people had Afghan nationality.  This finding was observed and confirmed in studies performed in Hamadan Provinces.  The main transmission route in these provinces is local transmitted form. Malaria is critical at Systan and Baluchestan Province because of immigration from Pakistan and Afghanistan. Analyzed data determined 418 out of 945 cases of malaria were immigrants from other countries.  It also reported that 3532 out of 4991 observed malaria cases in Khorasan Province in 1986-1990 were transmitted from abroad. 
According to the National Strategy Plan for Malaria Control, in respect to malaria status, the total country has been classified into four strata: 
- Areas where local transmission of malaria occurs, such as areas in Sistan and Baluchestan, Hormozghan and southern parts of Kerman Provinces and occasionally some areas in Ardebil, Boushehr, Fars and Khorasan Provinces.
- Areas where the imported cases are found and the potential risk of malaria transmission exists, such as areas in Gilan, Mazandaran, and Golestan Provinces.
- Areas where the imported cases are found, but there is no risk of malaria transmission, such as Yazd, Kurdistan, and Hamadan Provinces.
- Areas where no malaria case was reported during the last 3 years. It seems there was no such area in Iran.
The main technical elements of the strategy of malaria control which should be applied in MCP all over the country, particularly in areas where there are local malaria transmissions or there is potential risk of malaria transmission, are usually the following:
- Early case detection and prompt treatment;
- Plan and implement suitable preventive measures including vector control’
- mproving information and reporting system;
- Providence and prevention of local malaria outbreak or epidemy;
- Carry on training and refreshing courses for senior staff and technical personnel;
- Establish continuous quality control system for malaria microscopic diagnosis and cross-checking of examined slides;
- Monitoring the response of P. falciparum and P. vivax to antimalarial drugs;
- Planning and performing basic and applied researches on the local existing malaria problems and
- Sustaining supervision and evaluation malaria control activities.
All of the above activities need financial and scientific support and supervision of the national health authorities and collaboration of academic and research centers as well as the international organizations such as Roll Back Malaria/WHO. ,
Awareness of the people for transmission route of the malaria, controlling visitors and immigrants of Iranian and non-Iranian nationality and treatment of them, continuously identifying the Anopheles mosquitoes and finally exchanging epidemiological data and drug resistance rate of the disease are the most influencing parameters to control malaria.
||Sadrizadeh B. Malaria in the world, in the eastern Mediterranean region and in Iran. Arch Iran Med 1999;2:31-7.
||Motabar M, Tabibzadeh I, Manouchehri AV. Malaria and its control in Iran. Trop Geogr Med. 1975; 27:71-8.
||Edrissian GH. Malaria in Iran: Past and Present Situation. Ir J Parasitol. 2006; 1:1-14.
||Sadrizadeh B. Malaria in the world, in the eastern Mediterranean region and in Iran: Review article. WHO/EMRO Report. 2001. p. 1-13.
||Manouchehri AV, Emadian ZM. A review of malaria in Iran. J Am Mosq Con Ass. 1992; 4381:385.
||Raeisi A, Shahbazi A, Ranjbar M, Shoghli A, Vatandoost H, Faraji L. National strategy plan for malaria control in I.R.Iran, 2004-2008. Diseases Management Center, Undersecretary for Health, Ministry of Health and Medical Education. Seda: Seda Publicaton Co. 2004. p. 23
||John DT, Petri WA. Markell and Vog`s Medical Parasitology. Sunders: Oklahoma; 2006. p. 4.
||Chwatt BL. History of malaria from prehistory to eradication. In: Wernsdorfer WH, Mac Gregor IA, editors. Malaria Principles and Practice of Malariology. London: Churchill Livingstone; 1989. p. 1-59.
||Nicholas J, Breman WJ. Malaria and babesiosis. In: Fauci A, Braunwald e, Martin JB, editors. Harrison′s Principles of Internal Medicine. 14 th ed. New York: Amazon Co.; 1998. p. 1180-9.
||Martens P, Hall L. Malaria on the move: Human population movement and malaria transmission. Emerging Infect Dis 2000;6:103-9.
||Kadir MA, Ismail AK, Tahir SS. Epidemiology of malaria in AlTameem province, Irag, 1991- 2000. East Mediter heal J. 2003;5:1042-7.
||Ghafari S, Kariminia H. Malaria in Mazandaran Province 1986-1996. Journal of Mazandaran Medical Sciences University. 1999;32:42-8.
||Rezai M, Khodaei MA, Khazaeir M. Epidemilogy of Malaria in Kermanshah Province of Iran 1987-1996. Symposium, Parasitology international 47(Suppl); 1998. p. 160.
||Motevali EM, Khademi MR, Sadri GH. Epidemiological study of Malaria and country′s indexes in Isfahan province during 1998-2002. Iran J Infect Dis Trop Med 2003;23:29-32.
||Garfield R. Malaria control in Nicaragua: Social and political influences on disease transmission and control activities. Lancet 1999;354:414-8.
||Naghili B, Moghaddas PS, Majid PA, Bozorg ZI. Clinical and epidemiologic study of Malaria in east Azerbaijan. Med J Tabriz Univ Med sci Heal Serv 1983;20:73-84.
||Ataian A, Paykari H, Noorian AA, Nazarnia ME, Hosseini SH, Shahidi J, et al. Imported Malaria in Zanjan province, northwest part of Iran. J Zanjan Univ Med Sci Heal Serv 1993;2:6-11.
||Fallah M, Mirarab SA, Jamalian SF, Ghaderi A, Zolfaghari A. Epidemiology of Malaria in Hamadan province during a 20-year period, 1980-2001. Bebood. 2003;17:36-44.
||Sadjadi SM, Saba MS, Sharifian J, Razani GH, Smavati SH, Dezfoolian H. A survey of Malaria in Hamadan province from 1980-92. Sci J Ham Univ Med sci Heal Serv. 1993;3:24-30.
||Karimi ZA, Mahmood ZA, Vatani H, Shirbazoo SH. An epidemiologic study of Malaria in borders of Sarakhs in Khorasan province. Iran J Infec Dis Trop Med. 2003;20:47-50.
||World Health Organization. A global strategy for malaria control. Publ. No. ISBN924 1561610, Switzerland. 1993.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]