Journal of School of Public Health and

Malaria has been prevalent for a long time in Iran. About 1000 years ago, the Iranian physicians such as Avicenna (979-1037) were acquainted to the clinical feature of the disease. The scientific study of malaria in Iran was started by Latycheve in 1921. Later on up to 1944, malaria have been studied by some Iranian and foreign investigators and it was found hyper-endemic in some littoral parts of Caspian Sea in the north and Persian Golf in the south and hypo-or meso-endemic in the central parts of the country. From 1941 to 1948 the anti-malaria campaign were using quinine for chemotherapy and chemoprophylaxis as well as anti-larval measures for vector control. From 1949 DDT was used for the control of the Anopheles vectors which were determined at that time as A.maculipennis and A.superpictus in the north and some central parts of Iran, A. sacharovi in the west and A.stephensi and A. culicifacies in the south parts of the country. At the present time A.d&aposthali and A.fluviatilis are also considered as malaria vectors and A.pulcherrimus as a suspected vector in the south parts of Iran.
Spraying (using DDT) and malaria surveillance (case finding and treatment) caused a great reduction in malaria incidence in the malarious areas, particularly in the north and central parts of the country. The Institute of Malariology was established in the Department of Medical Parasitology, Medical School of Tehran University for training and research works on malaria in 1952.Malaria Eradication Programme (MEP) was recommended by the World Health Organization in 1956 and actually started in 1957 in Iran under General Office of Malaria Eradication (GOME) in the Ministry of Health.
Anti-malaria campaign in MEP during 1957-1971 caused interruption of transmission of malaria in the north parts of Zagross mountains, approximately, half north parts of Iran, and reduced, greatly, the incidence of the disease in the south parts of Iran which were considered as problem or refractory areas.
In 1973, GOME became a division of CDC in Ministry of Health and this integration caused some standstill in the activities of MEP. Thus, the incidence of malaria increased in the refractory areas in the south as well as in consolidation areas in the north parts of the country and the total diagnosed cases of malaria in Iran raised from less than 35,000 to approximately 100,000 cases per year. Therefore, the Ministry of Health strengthened the MEP again. Actually, from 1980 the anti-malaria campaign from MEP changed to malaria control programme , because in the refractory areas due to some behaviors or resistance of vectors to insecticides and, partly, due to the resistance of P.falciparum to chloroquine at RI & RII levels, the interruption of transmission was not possible. However, there was about 80% reduction of annual malaria incidence as well as percentage of P.falciparum during the recent decade. The prevalent species of Plasmodia are P.vivax & P.falciparum in the malarious areas of south and P.vivax in the north parts of Iran. P.malariae is rarely found at present time.

One of the main problems in malaria control is the resistance of Plasmodium falciparum to chloroquine and some other antimalarial drugs. This resistance is now quite common in most regions where falciparum malaria is endemic. Between 1968 and 1976, two in-vivo studies were carried out in endemic areas in the south of Iran and they showed P. falciparum to be chloroquine-sensitive. In 1983, the Department of Protozoology in the School of Public Health undertook in vivo and in vitro studies on the response of P. falciparum to chloroquine and other antimalarials. In the Iran-Shahr region a few cases of in vivo resistance to chloroquine were found in 1983, and the rate of resistance was 5.7% at RI level. Between 1994 and 1996, resistance in this region gradually increased to 51.2% at RI, RII and RIII. In Bandar-Abbas and Kahnoudj areas, prevalence of chloroquine-resistant P. falciparum infection was 32.5% at RI and RII from 1986 to 1987 it increased to 64.8% at RI,RII and RIII levels from1994 to1996 and then altered between 68% and 84% at RI and RII levels in the 1997-2001 period. 88 chloroquine-resistant patients were treated with standard doses of sulfadoxine-pyrimethmine (Fansidar) alone or in combination with amodiaquine and then examined with 28-day in-vivo tests. In 13.6% of them resistance was observed at RI and RII levels. In micro in-vitro tests, using WHO standard kits, the rates of resistance of P. falciparum to chloroquine, amodiaquine, sulfadoxine-pyrimethamine, mefloquine and quinine were 33.4%, 15.2%, 17.9%, 2.2% and 0.0% in 281, 72, 39, 44 and 72 cases respectively. As mefloquine has never been used in the studied areas, the sporadic cases of in-vitro mefloquine resistance may be considered as cases of innate and/or imported resistance. Primary resistant casese was seen mostly among Afghan and Pakistani immigrants/passengers. Hence these individuals are likely to have introduced chloroquine–resistant malaria into this country. The in vivo response of Plasmodium vivax to chloroquine was also studied in 827 patients was also studied in the endemic areas of the South-East between 1995 and 2001. The mean parasite clearance time (MPCT) was 2.78 and no resistant cases were found. Most cases in these studies had been referred by the local Malaria Control Laboratories to the research facilities at Health Training and Research Centers in Bandar-Abbas and Iran-Shahr. Some had received chloroquine, and those with a good response had not been referred. Therefore, the high rates of chloroquine resistance found in these studies probably do not reflect overall resistance rates at population level. To determine true resistance levels in these areas, all eligible patients must undergo WHO’s simplified in-vivo tests performed by trained malaria microscopists or laboratory technicians.

Background and Aim: Malaria threatens more than half of the world's population in about 100 countries. During the period 1921-1951 malaria was one of the most important public health issues in Iran, no other disease causing as much financial loss and mortality as malaria did. The objective of this study was to investigate malaria epidemiology in Iran during the period 1940- 2006 (65 years), in the hope that the infotmation and experience will be used in the future.

Materials and Methods: This study included a review of the available literature on the suject, as well as a study of health systems, existing records, and analysis of data and information on malaria in Iran. Data were colected from three main sources: national or international electronic sources (26 sources) non-electronic sources, including theses, journal articles, and various documents and reports, as well as data obtained from the national malaria surveillance system (a total of 180) and interviews with five informed and expert individuals. In addition, national documents prepared by the Center for Disease Control, Ministry of Health and Medical Education, during the previuos 6 months were made available to, and used by, the research team.

Results: The findings show that, despite several annual fluctuations, the trend of incidence of the disease during the 65-year period, from 1940 to 2006, was a downward trend. The incidence declined from 250-333 per 1000 people in the early 1940's to 0.22 per 1000 people in 2006.

Conclusion: The changes in incidence of malaria show that elimination of malaria is a possible and feasible goal. The experiences achieved in controlling this disease can be utilized for controlling other diseases as well.

Background and aim:  Malaria as a mosquito-borne disease is largely dependent on climatic conditions. Temperature, rainfall and relative humidity are considered as climatic factors affecting the geographical distribution of this disease. These climatic factors have definite roles not only in the growth and proliferation of the mosquito Anopheles but also in the parasite Plasmodium activity. The purpose of this study was to find in which regions of Iran climatic conditions favour spread of malaria.

Material and Methods: Data on 3 climatic factors, including the mean monthly temperature, rainfall and mixed ratio of humidity, obtained from 31 synoptic meteorological stations during the 30-year period 1975-2005 were used. By running the informative filters through map algebra tools in the Geographical Information System (GIS), the synoptic meteorological stations were classified into 4 groups in terms of climatic conditions favouring activity and proliferation of the mosquito Anopheles and the parasite Plasmodium. Then the regions were interpolated in terms of climate risk of malaria incidence using the tension Spiline interpolation method.

Results: The maps of climatic potential malaria risk indicated that the southern provinces including Hormozgan, Bushehr and Khuzestan, southern parts of Sistan-Balouchistan province, such as Chabahar and Nikshahr, as well as Northern provinces of the country, including Mazandaran and Gilan, have the highest climatic potential for risk of malaria spread. On the other hand, provinces in the North Western region, including West and East Azarbaijan, Ardebil, Kurdistan and Zanjan, have the lowest climatic potential risk of malaria spread. Further analysis of the data showed that a large segment of the population is living in regions with medium- to high-risk zones.

Conclusion: The findings of this study can be used when designing malaria control programs to identify different regions in terms of climate-based malaria risk. The presented risk map of malaria in this study is completely based on climatic factors. The disconformity between these presented climate-based maps and the observed high-risk map is due to such factors as socioeconomic and lifestyle changes, as well as border problems (foreign subjects entering the country).

  Background and Aim: Malaria remains an important vector-borne disease globally and is a threat for human life. Forty percent of the world’s populations who are living in low-income countries are at risk of malaria. The disease exists in Iran and caused economic and social damages. As result of malaria control program that has been done during the past years, the disease is eliminated from the most parts of the country, so that it is only reporting from a small part in these years.

  Materials and Methods : During this study, all available papers, books and thesises were reviewed and articles from Iranmedex, DIS and PubMed databanks were also used. Furthermore the related reports from different sources were noted.

  The extensive studies have important information about malaria vectors. In this study the data about malaria vectors and related training courses are listed. During this study the related papers, Books and thesises which have been reviewed.

  Although efforts, surveillance system, diagnostic and treatment facilities, as well as knowledge and attitude of peoples regarding to health behavior are improved nowadays, there are significant improvements about decreasing the malaria cases. Risk of the disease exists because of population exchange and asymptomatic cases. The malaria can be studied with both public health and economical aspects. This paper represents entomological studies of malaria during 1935 by the end of 2008.

  Conclusion: our study revealed that, based on recent malaria national program, the authorities should make an emphasis on vector control monitoring, resistance management, malaria evaluation and because of weak supervision on all malaria operation at stage of elimination of malaria, accurate and careful suppersional require to reach the objective and goal of elimination.

  Background and Aim: specific and scientific study in the field of malaria in Iran commenced simultaneouoly with establishing the Instituted of Malariology in Tehran University. Subsequently the Institute was changed to school of Public Health and Institute of Public Health. Research which this new situation resulted in increasing studies and researches in the field of malaria based on three main items as entomology and vector control, parasitology and epidemiology. Historical study of malaria prepares a worthy opportunity to remind the pioneers and those who dedicated their life for combating malaria. In this study the situation of published papers, prepared theses by Iranian researchers and specific training and fresher training courses in the filed of malaria parasitology during the last fifty years were considered.

  Materials and Methods: This study was conducted as a retrospective study based on the collecting all available data from internal and external electronic sources, papers, books, reports, theses. Moreover, some interviews were made with relevant knowledgeable individuals, in the field of malaria parasitology in Iran.

  Results: In this study 143 papers in the field of malaria parasitology were collected in Persian and English languages. Thirty five MSPH, MPH, PhD these and forty four specific courses were recorded as well.

  Conclusion: The collected data indicating the correct comprehension of Iranian researchers from importance of malaria infection and its parasitology in Iran. The facts also show that specific training and retraining of malaria microscopy played considerable role in the control of malaria in Iran.

  Background and Aim: Environmental and ecological factors especially climatic conditions have a significant impact on the prevalence of parasitic diseases. These factors has is more importance in Malaria Incidence and Epidemiology. Malaria as the most important parasitic disease, considered as one of most important public health problem. The climatic factors not only affect the growth and proliferation of the Anopheles mosquito but also affect in Plasmodium activity . In present study we surveyed the malaria situation during 1972 to 2005. In order to the five climatic parameters including mean temperature, total precipitation, number of days with precipitation over 0mm, rainfall distribution index and relative humidity were used as annual average during 1971 to 2005.

  Materials and Methods : we calculate average of annual of climatic parameters for the 31 synoptic stations of Iran Using GIS software. First, using the ordinary Kriging model with spherical a Semi variogram was traced maps of climatic parameters and these factors mean was calculated for each year . Finally, to investigate the relationship between climatic parameters with the prevalence index the Pearson correlation coefficient at 0.9 confidence level (p = 0.10) . was used. A multivariate linear regression model was applied to estimate the prevalence of disease based on the mentioned climatic factors .

  Results : Study of malaria prevalence in 1971 to 2005 showed cases of disease with has a decreasing trend with slope 0.0142 in year that this trend has been accelerated from 1375 . Many cases of disease have been reported one year after increased precipitation . The result showed the weather humidity factors is important than temperature factors in the prevalence of malaria . I general, the developed model is explained 0.48 of changes prevalence time.

  Conclusion: In order to be successful Anti-malaria campaign in Malaria-prone areas in addition different influencing factors climatic factors should be considered .

  Background and Aim : The National Malaria Control Program was developed, in 2011, into the National Malaria Surveillance Program. It is one of the most comprehensive surveillance systems in Iran. The aim of this study was to evaluate the impact of malaria elimination program on data quality and accuracy in the national malaria surveillance system.

  Materials and Methods : This was a cross-sectional study conducted in four malaria-prone provinces in Iran to determine and assess the completeness and accuracy of the information collected in the malaria surveillance system. The purpose was to compare data reporting forms 3 and 4 (reporting positive cases from selected district health centers) between two time points, namely, 2009-2010 (before starting the program) and 2010-2012 (after starting the program).

  Results: The total number of reporting forms included in the study was 1927, nearly 54% from the initial time point and the rest from the final time point. The highest and lowest proportions were 94.78% and 17.30% from Iranshahr and Hormozgan University health centers, respectively. On the whole, the degree of completeness of the forms was 84% (83.7% and 85% before and after starting the program, respectively). Based on the Chi-square test, the differences were not statistically significant.

  Conclusion: Only a minor change occurred in the degree of completeness of the forms between the two time points: a 4% increase in form 4 and a 3% decrease in form 3. It can be concluded, then, that the elimination program h ad no significant effect on the completeness and accuracy of the reporting forms.

  Background and Aim : Asymptomatic malaria is a great challenge in the control, elimination and eradication programs of the disease in the endemic areas. The infected individuals with asymptomatic malaria are not cured and are, consequently, a potential source for contamination of the mosquito vectors and spread of the disease in the area. Therefore, detection of asymptomatic infected people is very important as regards combating the disease. This study was conducted to determine the presence and prevalence of asymptomatic malaria in Jask district, Hormozgan Province, Iran during 2012-13, in the hope that the results will help in designing strategies to eliminate the disease in the area.

  Materials and Methods: A total of 200 persons under coverage of health centers in Jask district were selected randomly and enrolled in the study. From each subject a 5-ml blood sample was taken in 3 occasions (total number of samples = 600), slides p repared and examined using microscopic and molecular (PCR) methods, as well as rapid diagnostic (RDT) tests.

  Results: None of the 600 slides prepared microscopically showed any positive malaria case. Neither did any of those prepared by RDTs or Nested-PCR.

  Conclusion : The findings of this study indicate that implementation of the malaria control program has been successful in the area therefore the malaria elimination program should continue.

Background and Aim: Considering the ongoing national malaria elimination program in Iran, establishing a bank of human Plasmodium genes and proteins can be very useful for research purposes. This study was conducted to collect some of the native isolates of human Plasmodia from endemic areas in the country.

Materials and Methods: A 2ml vein-punctured blood sample was prepared from each confirmed malaria case. The samples were dispensed in EDTA pre-dosed tubes and cryopreserved for further tests. Moreover, relevant Geimsa-stained thick and thin blood smears were kept in a safe place. Tests for genetic indicators of MSP-1 was performed for each of the P. vivax samples with the RFLP-PCR techniques. In addition, an in vivo drug sensitivity test was performed for each P. falciparum case. Collecting and cryopreserving samples will continue.

Results: A total of 131 samples, including 109, 19 and 3 P. vivax, P. falciparum and mixed samples, respectively, were preserved with relevant data such as species, parasitaemia and nationality of the donor. MSP-1 gene classification resulted in three different haplotypes including Hap.1, Hap.2 and Hap.3 with frequencies of 20.6%, 41.2% and 38.2%, respectively. The In vivo drug sensitivity tests on P. facilparum isolates showed that all of the isolates were sensitive to the current drug of choice, namely, a combination of artesunate and fansidar.

Conclusion: This study resulted in the preservation of considerable amounts of P. vivax and P. falciparum samples for further relevant studies and research purposes.

Background and Aim: Malaria is still one of the major health problems in comparison with any other parasitic disease in Iran with considerable economic and mortality consequences. Sistan-and-Baluchestan, Hormozgan and Kerman are the most affected provinces in the country approximately 96% of the cases are reported from these three provinces. The aim of this study was to determine the frequency, distribution and rate of parasitaemia of human Plasmodium (P.) species in patients infected with malaria parasites in Kerman province.

Materials and Methods: A total of 92,798 peripheral blood smears were collected from suspected malaria patients during the period 2009-10. Thin and thick blood smears were prepared according to the World Health Organization (WHO) standard procedure. Percentage of parasitaemia was determined based on the number of parasites in the positive slides. The Chi-square test was used for data analysis.

Results: A total of 571 samples were found to contain human Plasmodium species, including 523, 44, and 4 cases of P. vivax, P. falciparum and mixed infection, respectively. The results also showed that, as compared with the previous year, the total number of P. vivax cases

decreased in 2010 by 33.96%. The highest level of parasitaemia was observed in one of the patients infected with P. falciparum, with 77240 parasites/µl of blood, and the lowest in a patient infected with P. vivax, with 48 parasites/µl of blood. There were no differences between the positive and negative cases as regards parameters such as nationality, habitat or gender (Chi-square, p<0.05).  Furthermore, based on the Mann-Whitney test, there was no significant difference between the mean counts of P. falciparum and P. vivax (p-value = 0.464).

Conclusion: Considering that Iran is in the elimination stage of malaria, patient finding and rapid, timely diagnosis of the disease are very important, particularly cases coming from Pakistan and Afghanistan, helping sustainability of the elimination program.