Socio-Political Background

WHO/CDS/RBM/

World Health Organization

Organisation mondiale de la Santé

DISTR: General and RBM Web site

4October 2001

RBM Complex Emergency Malaria Data Base

AFGHANISTAN

Jayne Webster (Malaria Consortium), RBM EMRO and the RBM Complex Emergencies team, Geneva

For the

RBM Technical Support Network on Complex Emergencies

Malaria control in Afghanistan was compiled using available information. Apologies are extended to any agencies carrying out activities that have been omitted from this report. Additional information is welcomed for updating this report

Table of Contents

SUMMARY

1. SOCIO-POLITICAL BACKGROUND

1.1 Basic Indicators

1.2 Economic situation

1.3 Government type

1.4 Legal system

1.5 Ethnic groups

1.6 Religion

1.7 The complex emergency

2. Refugees and Internally Displaced People (IDPs)

2.1 History

2.1.1 Refugees

2.2.2 Internally displaced persons (IDPs)

2.2 Present Situation

2.2.1 Refugees

2.2.2 Returned refugees

2.2.3 IDPs

3. MALARIA SITUATION

3.1 Epidemiological

3.2 Environment and Transmission

3.3 Parasites

3.4 Malaria Burden

3.4.1 Prevalence surveys

3.4.2 Health facility based data

3.5 Malaria management

3.6 Drug resistance

3.7 Vectors

3.8 Insecticide resistance

3.9 Impact of the complex emergency

3.9.1 Refugees

3.9.1.1 Malaria in Northern Pakistan

3.9.1.2 Malaria in Iran

3.9.2 IDPs

3.10 Epidemics

3.10.1 Potential

3.10.2 Recent epidemics

3.10.3 Surveillance systems

3.10.4 Preparedness

3.11 Recent control measures Eastern Region

3.11.1 Clinical Management

3.11.1.1 Improved diagnostic and clinical services

3.11.2 Personal protection

3.11.2.1 Repellent

3.11.2.2 Insecticide treated mosquito nets (ITNs)

3.11.2.2.1 Health education and ITNs

3.11.2.2.2 Sales strategy

3.11.2.2.3 Promotion of ITNs

3.11.3. Urban control in Jalalabad city

3.11.3.1 Gambusia fish project

3.11.4 Community based malaria control

3.11.5 Cattle sponging

3.12 Recent control measures in other regions

3.13 Cultural factors

3.13.1 Perceptions of malaria

3.13.2 Traditional practises

3.13.3 Treatment seeking behaviour

3.14 Recommended prophylaxis and stand-by treatment for international staff

4. HEALTH SERVICES

4.1 Statistics

4.2 Health policy in relation to malaria

4.3 Coverage by health facilities

4.4 Access to health services by women

4.5 Health personnel, training and institutions

4.6 Health systems

4.7 Health partners

5. Miscellaneous

5.1 Suppliers

5.1.1 Nets

5.1.2 Insecticides

5.1.3 Drugs

5.1.4 Laboratory reagents

5.2 Key contacts

5.2.1 Agencies

5.2.2 MOPH

5.3 Key references

5.3.1 Reviews

6. PAKISTAN

6.1 Tent spraying during the acute phase of the emergency

6.2 Insecticide treated mosquito nets (ITNs)

6.3 Permethrin treated clothing or bedding

6.4 Other methods of personal protection

6.5 Indoor spraying

6.6 Livestock sponging

ANNEX1HealthFacility,InfrastructureandCapacity 41SUMMARY

DISEASE 1: MALARIA

Infective agent

/ In Afghanistan 10-20% of all malaria cases are caused by Plasmodium falciparum. This is the most life threatening form of the disease.
The remainder, 80-90% of cases, are caused by Plasmodium vivax, which causes the less severe form of disease.
Case definition / Uncomplicated Malaria
Person with fever or history of fever associated with symptoms such as nausea, vomiting and diarrhoea, headache, back pain, chills, myalgia, where other infectious diseases have been excluded.
Severe Malaria
Person with fever and symptoms as for uncomplicated malaria but with associated signs such as disorientation, loss of consciousness, convulsions, severe anaemia, jaundice, haemaglobinuria, spontaneous bleeding, pulmonary oedema, shock.
To confirm case:
Demonstration of malaria parasites in blood films by examining thick or thin smears or by rapid diagnostic kit for P.falciparum.
Mode of transmission / Mosquito bite: Anopheles Superpictus is the main vector of importance.
Other vectors present include: An. s stephensi, An. Culcifaces and An. Pulcherrimus
Incidence/prevalence in the area / In 1999, on an estimated total population of 21 million people, over 12 million were estimated to be living in areas with malaria risk, resulting in an estimated 2-3 million clinical malaria case. However, only, 395,600 cases were reported by the health services in that year. Approximately 80-90% of malaria cases is due to P. vivaxand 10-20% is due to P. falciparum (with 300,000-450,000 estimated cases per year).
Geographical distribution / Malaria is endemic throughout Afghanistan at altitudes below 1500 m especially the rice growing areas, but it also occurs in urban areas such as Kabul and Jalalabad. The central highlands are malaria free. Transmission is dependent upon altitude, temperature and rainfall.
Eastern zone: transmission is highest in rice growing areas.
Seasonality / Transmission is seasonal and unstable. Can be summarised as non-malarious to mesoendemic.
In Afghanistan, vivax and falciparum malaria transmission is highly seasonal. Transmission starts normally in May/June, peaking in October-November, and diminishing rapidly in December with the onset of winter and corresponding drop in temperature.
Transmission of vivax and falciparum malaria in Pakistan is year-round with seasonal peaks, mostly after the July-August monsoon.
Outbreak threshold
Last epidemics in the area / In September 1999 there was a malaria outbreak in Nazian Eastern Afghanistan, the population of the areas is 8,500 and up to 15% of the population were reported as having confirmed P.falciparum malaria. No deaths were recorded and the outbreak was controlled. In the same month there was a P.falciparum malaria outbreak in Qalai Nao of Badghis province. Out of 293 cases, 8 deaths were recorded.
In November 1999 there was another malaria outbreak in Narang in Kunar Province. The population of this area is 23,000 and the prevalence of P.falciparum was reported as over 30%. Two deaths were reported and the outbreak was controlled.
Other outbreaks have been reported from the north of the country, in Faryab (22% P.falciparum prevalence), Heart, Baghlan and Kundus. No details of numbers affected or control measures are known.
In September 2000 there was a P.falciparum malaria outbreak in Yakawlang district of Bamyan province with 15 deaths reported.
Factors that increase the risk of transmission / Major risk factors include:
1. Population movement
2. Sudden increase in vectorial capacity as a result of unusual weather
3. Drug and insecticide resistance
- Mass migration / Yes:
There is a potential for epidemics due to the movements of people in two forms.
The influx of non-immune population (such as from the central highlands) into the malarious areas of the north (Faryab and Samangan provinces), the northeast (the whole region), the east (Nangahar, Laghman and parts of Kunar province), the south (Helmand and Kandahar provinces), the west (parts of Farah province, Shinand and Torghundi districts in Heart province).
Introduction of a number of infected individuals into a malaria-free area. This was clearly demonstrated in Badghis province outbreak in 1999 that claimed 8 lives and also in Yakawlang outbreak in September 2000 that claimed 15 lives. It is believed that displaced people from the neighbouring Faryab province introduced the P. falciparum to Qalai Nao of Badghis province, while merchants from Yakawlang district who used to travel to Baghlan and Saripul provinces are thought to have introduced the parasite to those remote malaria-free villages.
- Mass aggregation / Yes: Increased risk of transmission
- Not access to health services / Yes: Delays in access to effective treatment increase likelihood of severe disease and death developing, as well as increase the human pool of malaria gametocytes (mature parasite stage in humans that once pick up by a mosquito then develops into the infective stage for transmission to another human) thus increasing transmission.
- Reduction of food intake / Yes: During widespread malnutrition people are more vulnerable to developing severe malaria (once infected) and case management is complicated, resulting in increased mortality.
- No availability of safe water / No
However, temporary surface water is key breeding site for malaria vectors and should be reduced avoided or controlled where possible.
- Others /

1. Lack of effective shelter increases exposure and therefore may increase number of infective mosquito bites per night
2. Lack of preventive interventions such as insecticide treated materials (bed nets, sheeting etc) and residual insecticide spraying of shelters can increase risk of transmission significantly
3. Insecticide resistance
4. Drug resistance: The spread of chloroquine resistance due to widespread practices of self-medication and non-compliance with treatment regimes is now widespread.
5. Sudden increase in vectorial capacity as a result of unusual weather
6. Many parts of the country were stricken by drought and witnessed prolonged periods of abnormal warm weather during the past two years. Unusual/unseasonal meteorological conditions are believed to have increased vector capacity and subsequent malaria transmission in the Yakawlang epidemic (2,400 meter).

Risk assessment conclusions / The majority of malaria case will be caused by P. vivax, which is rarely life threatening. The minority of cases will be P. falciparum which can cause severe disease and death.
The peak season for malaria is October/November in this region. There are estimated to be over 3 million displaced, many fleeing highland areas (with less malaria) and moving to, or through areas of higher malaria transmission. This specific group of displaced has low immunity to malaria displaced from these and increased risk for the next 6-7 weeks.
Long term drought across the country has resulted in increasing malnutrition. All malnourished are at increased risk of disease, particularly young children.
Those communities displaced to border regions of Pakistan and Tajikistan where malaria transmission is greater are most at risk both during the remaining transmission period and from the start of the new transmission season in April/May
Control and response measures (including treatment and vaccination) / Good access to effective diagnosis and treatment of existing cases (see WHO emergency treatment recommendations)
Vigourous health education at community level to improve rapid treatment seeking behaviour
Intermittent preventive therapy (with SP) for pregnant women where possible
Effective prevention approaches to reduce risk of infection include; residual insecticide spraying of shelters, insecticide treated materials programmes (ITNs & Chadors) and cattle sponging.

List of Tables

1. Basic indicators of the population
2. Ethnic groups of Afghanistan
3. Refugee returns for 1997 and 1998
4. Comparison of the basic indicators of the countries of asylum with those of Afghanistan
5. Numbers, origin and place of displacement of Internally displaced people (IDPs) in 1999
6. Malaria prevalence surveys in Eastern Zone October to November 1998
7. Health facility data from 5 Northern Provinces April 1991 to December 1994
8. Annual reported malaria cases in Afghanistan (Jan-Dec 1999)
9. Major vectors of Afghanistan: breeding places, biting and resting habits
10. Health service statistics

List of Maps

1. General position of Afghanistan
2. Areas of return of refugees (to the beginning of 1996)
3. Settlement areas of Afghan refugees in Iran and Paskistan
4. Relief map of Afghanistan showing low-lying areas with increased risk for malaria

Acronyms

An. culcifacesAnopheles culcifaces

An. pulcherrimusAnopheles pulcherrimus

An. stephensiAnopheles stephensi

An. superpictusAnopheles superpictus

ARCAfghan Relief Committee

CHACoordination of Humanitarian Assistance

DDTDichlorodiphenyltrichlorethane

HNIHealthNet International

HNI/MCP HealthNet International Malaria Control Programme

ICRCInternational Committee of the Red Cross

IDPInternally Displaced People

IIROIslamic International Relief Organisation

IMRInfant Mortality Rate

ITNInsecticide Treated Mosquito Net

MOPHMinistry of Public Health

MRCMalaria Reference Centre

NGONon Governmental Organisation

NWFPNorth West Frontier Province

OPDOut Patients Department

P.falciparumPlasmodium falciparum

P.vivaxPlasmodium vivax

RBM/EHARoll Back Malaria/Emergency and Humanitarian Aid

SCASwedish Committee for Afghanistan

UNHCRUnited Nations High Commissioner for Refugees

UNOCHAUnited Nations Office for the Coordination of Humanitarian Affairs

WFPWorld Food Programme

WHOWorld Health Organization

AFGHANISTAN

Map 1 : General position of Afghanistan

1. SOCIO-POLITICAL BACKGROUND

1.1 Basic Indicators[1,2,3]

Table 1: Basic indicators of the population

Total population (1998) / 21,354,000
Average annual growth rate (1978-1998) / 2.5
Age distribution <15 years % / 50.2
Infant Mortality Rate IMR per 1,000 (1978) / 182
Infant Mortality Rate IMR per 1,000 (1997) / 165
Maternal Mortality Ratio per 100,000 (1990) / 1,700
Adult literacy rate >15 years can read and write % (1995)
Male / 47
Female / 15
Urban population % of total population (1999) / 25

1.2 Economic situation[3]

Afghanistan is an extremely poor country highly dependent on farming and livestock raising (sheep and goats). Gross domestic product has fallen substantially over the last 20 years because of the loss of labour and capital and the disruption of trade and transport. Much of the population continues to suffer from insufficient food, clothing, housing, and medical care. Inflation remains a serious problem throughout the country. Government efforts to encourage foreign investment have been unsuccessful. Numerical data are either unavailable or unreliable. Afghanistan’s infrastructure and industrial base have disappeared and there is little for former refugees to do but survive on subsistence agriculture and small-scale trade.

1.3 Government type

Transitional government

1.4 Legal system

A new legal system has not been adopted, but all factions tacitly agree they will follow Shari’a (Islamic Law)

1.5 Ethnic groups[4,5]

Table 2: Ethnic groups of Afghanistan

Ethnic Group / Number / Location / Language
Pashtun / 7 million / Mainly eastern and southern Afghanistan, Kabul, NWFP Pakistan / Pashto
Tajik / 3.5 million / North eastern Afghanistan, Heart and Kabul / Dari
Hazara / 1.5 million / Hazarajat, Kabul, Mazar-e-Sharif, Quetta & Baluchistan (Pakistan) / Dari dialect
Uzbek / 1.3 million / Northern provinces of Jowzjan, Balkh, Baghlan and Kunduz between the Amu Darya and the Hindu Kush range / Uzbeki (Turkic)
Aimaq / 800,000 / North western provinces / Dari
Turkmen / Estimates
125,000 to 600,000 / Northern and north western provinces bordering Turkmenistan / Turkmeni
Baluch and Brahui / 300,000 / Southwest bordering on Iran and Baluchistan/Pakistan / Baluchi, Pashto
Nuristani / 100,000 / Nuristan, eastern Afghanistan / Nuristani
Kuchi / Estimates 500,000 to 3 million / South western Afghanistan on borders with Iran and Pakistan

The people of Afghanistan are ethnically, religiously and linguistically mixed.

1.6 Religion

80% Sunni Muslim and 20% Shi’a

Sunni Muslim is the dominant faith

1.7 The complex emergency

1979December: Soviet troops invade Afghanistan

1989February: Soviet troops withdraw from Afghanistan

1992April: Mujahidin government takes power in Kabul

1994November: Taliban capture Kandahar

1995September: Taliban capture Heart

1996September: Taliban capture Jalalabad and Kabul

1997Taliban capture Mazar-e-sharief and then lose it to the opposition

1998Taliban recapture Mazar-e-sharief

1998Taliban capture Bamyam province and the rest of the highlands

2000Taliban capture Taloqan the capital of Takhar province

The relationship between the Taliban regime, and both NGOs and UN agencies has been tense. The Taliban has always viewed the influences of the West as a treat to Afghanistan’s religious tradition.

In November 1999, the United Nations (UN) imposed limited sanctions against the Taliban regime. This caused frustration amongst Afghans, and attacks on UN buildings in urban centres including Kabul and Jalalabad were reported. Since the 11 September 2001 attacks on the USA and the increasing treat of an international attack on terrorist groups in Afghanistan most international agencies have evacuated.

2. Refugees and Internally Displaced People (IDPs)[4,5]

2.1 History

2.1.1 Refugees

1978 People’s Democratic Party of Afghanistan (PDPA) took power through a military coup, resulting in the fleeing, within one year, of 400,000 Afghans to North West Frontier Province (NWFP) in Pakistan and 200,000 to Iran.

1979 December – Soviet troops enter Afghanistan, within one year 1.9 million refugees had left Afghanistan.

1985 –1990 according to UNHCR figures 6.2 million Afghans were living in Pakistan and Iran alone (includes children born in exile)

1989 February - Soviet troops withdrew from Afghanistan, many families who had spent the war in the mountains returned to their villages. But only small numbers of people returned from Pakistan and Iran.

April - Mujahidin government took power in Kabul and refugees return from NWFP Pakistan on a massive scale. Refugees also started to return from Iran

1994 continued conflict inhibited further return of refugees from Iran. The capture of Kandahar by Taliban in November brought about the return of a number of refugees from Pakistan.

1995capture of the whole of Western Afghanistan by Taliban brought the return of refugees from Iran to a halt, thousands of people returned to Iran

The areas of refugee return upto the beginning of 1996 are shown in Map 2 below. It can be seen that the highest numbers of refugees returned to the Eastern Zone (30 to 50%), followed by 20 to 30% to Southern and Western districts of Afghanistan.

199650,000 fled to Pakistan upon the capture of Jalalabad and Kabul by Taliban. Refugees began to return to southern Afghanistan, as the Taliban brought about security there.

2.2.2 Internally displaced persons (IDPs)

1979-1989Many families spent the years of the Soviet occupation in the relative safety of the mountain areas.

1992 the first major movement of IDPs to Mazar-i-Sharif following the rocketing of Kabul

1994 heavy rocketing of Kabul resulted in the development of two enormous refugee camps near Jalalabad and a further exodus to Peshawar NWFP

1996Capture of Jalalabad and Kabul by the Taliban

1997Capture of Shomali plains north of Kabul by Taliban causes 200,000 to flee to Kabul

1999,2000 Drought resulted in loss of livestock and displacement of Kushi (nomad tribes) to the western, southern and northern provinces. There are 50,000 IDPs in Heart in 6 camps.

2000Capture of Taloqan causes mass exodus to Faizabad, the capital of Badakhshan province. There are also 114,000 IDPs on the river islands north of Kunduz fleeing the conflict.

An estimated one million Afghans have been internally displaced in the last 5 years alone. Since 11 September 2001 several million people have fled towns and villages of origin fearing a military attack.

A co-operation and resource-sharing agreement between ICRC, UNHCR, UNOCHA and WFP was signed in 1997. Under the agreement ICRC was designated the ‘reference’ agency for IDP issues in Afghanistan.

Map 2 : Areas of return of Refugees (to the beginning of 1996)
[6]

2.2 Present Situation

2.2.1 Refugees

Since 1978 over 6 million refugees have left Afghanistan mainly to the neighbouring countries of Pakistan and Iran, but also to Europe, North America and India.

The positions of the main refugee areas in Iran and Pakistan are shown in Map 3 below.

It can be seen that the main areas of refugee settlement in Pakistan were on the borders with Afghanistan, whereas in Iran they were in the midst and to the west of the country, including along the border with Iraq.