Severity of Plasmodium vivax Malaria among Patients Presenting at Tertiary Care Hospital after Flood in Sindh – Pakistan

grave health issues. Pakistan is one of the adversely hit country by malaria. We conducted this study to access whether there was only increase in no of malaria patients after �ood in Sindh patients or clinical variance is also there. Objective: To assess the severity of Plasmodium vivax infection at a tertiary care hospital, after �ood situation in Sindh. Methods: This cross-sectional study was conducted at LUMHS, Jamshoro from November 2022 to April 2023. After taking inform written consent, adult patients of age 13 to 60 years, irrespective of gender, with positive report of P. vivax malaria were included in the study. Data were recorded on predesigned proforma. Severity of malaria was determined according to the classi�cation criteria. Data were analyzed with the help of SPSS version 23. Results: Out of total 170 patients, 52.4% female, mean age was 26.6 year. 50.6% patients of Plasmodium vivax found to suffer from severe malaria. Severe anemia, ALOC and jaundice were present in 28.2%, 21.2% and 11.2% of patients respectively. Conclusions: Enormous number of severe malaria cases due to of P. vivax was detected after �oods in Sindh. Young age people were affected more, irrespective of gender. Severe anemia was the most common complication of malaria. Thrombocytopenia found frequently in patients infected with P. vivax .

ranged from 70% to 81% followed by Plasmodium falciparum and very little contribution from other plasmodium variants [5,6].Traditionally, Plasmodium vivax is thought to be a benign disease as parallel to falciparum but since last few years more troublesome and even lethal outcomes are being noted [7].Plasmodium is affected by many factors including climate.In Pakistan, KPK is worst malaria affected area followed by Sindh [8].Knowledge is required about genetic makeup, disease producing properties qualities clinical presentation and drug response of the locally prevalent plasmodium species for proper control of disease, unfortunately scanty literature is available [6].Research on these parameters is the need of Severity of Plasmodium vivax Malaria

I N T R O D U C T I O N
Malaria is one of the widely spread vector bond infectious disease responsible for grave health issues.Pakistan is one of the adversely hit country by malaria.We conducted this study to access whether there was only increase in no of malaria patients after ood in Sindh patients or clinical variance is also there.Objective: To assess the severity of Plasmodium vivax infection at a tertiary care hospital, after ood situation in Sindh.Methods: This cross-sectional study was conducted at LUMHS, Jamshoro from November 2022 to April 2023.After taking inform written consent, adult patients of age 13 to 60 years, irrespective of gender, with positive report of P. vivax malaria were included in the study.Data were recorded on predesigned proforma.Severity of malaria was determined according to the classi cation criteria.Data were analyzed with the help of SPSS version 23.Results: Out of total 170 patients, 52.4% female, mean age was 26.6 year.50.6% patients of Plasmodium vivax found to suffer from severe malaria.Severe anemia, ALOC and jaundice were present in 28.2%, 21.2% and 11.2% of patients respectively.Conclusions: Enormous number of severe malaria cases due to of P. vivax was detected after oods in Sindh.Young age people were affected more, irrespective of gender.Severe anemia was the most common complication of malaria.Thrombocytopenia found frequently in patients infected with P. vivax.

A R T I C L E I N F O
A B S T R A C T time.Recently Pakistan was hit by troublesome oods, apart from mass destruction and human losses it also became the reason for dramatic increase in infectious disease including malaria [9].We conducted this study to access whether there was only increase in no of patients or clinical variance is also there.Malaria is one of the widely spread, vector bond infectious disease responsible for grave health issues [11].Malaria can manifest itself from inconspicuous infection to severe malaria which may be life threatening.Once assumed to be an innocent disease P. vivax is now increasingly being documented as an important cause of severe malaria [12,13].We conducted this study to access post ood situation of vivax malaria, whether there were only increases in the number of P. vivax malaria cases or variation in clinical spectrum of the disease was also there.In Pakistan, Sindh was tremendously hit province by oods.Apart from other

R E S U L T S
Total 170 patients were enrolled both from medical wards and OPD, who ful lled the inclusion and exclusion criteria.
In our study male were 47.6% while female were 52.4%.Age ranged from 13 years to 85 years so mean age was 26.6 year.Out of these 170 patients 50.6% patients of Plasmodium vivax found to be suffered from severe malaria (Figure 1).Severe anemia, ALOC and jaundice were present in 28.2%, 21.2% and 11.2% of patients and the criteria of severe malaria present in selected patients showed in Table 1. 12 ×10 /L and Maximum was 358 ×10 /L while mean value was 9 64.6882 ×10 /L (Table 2).S  .In contrast to our study, where we found no patient with signi cant hypoglycemia (i.e., less than 40 mg/dL), in one study authors found hypoglycemia in 48%, and liver and kidney failure in 30% [21].

FREQUENCY OF P VIVAX
It is noted that younger age people were affected more from P. vivax and an enormous number of P. vivax positive patients manifested as severe malaria cases with anemia and thrombocytopenia as common comorbid ndings.Healthcare awareness regarding the elimination of the hypnozoite stage, and implement rigorous vector control measures for disease prevention should be promoted.
[6]s cross-sectional study was conducted at a premier tertiary care hospital i.e.Liaquat University of Medical & Health Sciences, Jamshoro which is represented hospital of whole interior of Sindh.The study was approved from the Research Ethics Committee of Liaquat University of Medical & Health Sciences, Jamshoro (Letter No./REC/-174; Dated 08-11-2022).The patients were selected via non-probability convenience sampling.Sample size was calculated via WHO Open Epi software by taking prevalence of P vivax in patients with severe malaria as 12.7% with Margin of Error as 5% and Con dence Interval of 95%[6].The duration of study lasted from November 2022 to April 2023 and the data were analyzed with the help of SPSS version 23.0.
All patients of age more than 13 years, irrespective of gender differences who were either admitted in medical ward or seeking consultation from in Medical OPD with positive report of P. vivax malaria were included in the study.Patients who were co-infected with Plasmodium falciparum, dengue or ITP were excluded from the study.Plasmodium vivax was detected by Giemsa stain, thick and thin blood lms or ICT Malaria.Data were recorded on predesigned proforma after taken written informed consent from participants.The proforma included demographic pro le, history, general and systemic examination of the patients along with lab investigations.Complete blood count, random blood sugar, (BSR), liver function test, urea, creatinine, serum bicarbonate urine examination, other speci c tests were done as per clinical judgment with an intent of treatment.Severity of malaria was determined according to the classi cation criteria established by CDC[10].

Table 1 :
Frequency of P. vivax in patients with severe malaria Patient Clinical Pro le

Table 2 :
Hematological Parameters among patients of P. vivax Malaria destruction, health was affected immensely.Rapid escalation in no. of malaria cases were documented in Sindh and Baluchistan, contributed 78% of all cases of malaria from Pakistan.Situation was so worse that only in the month September 2022, 210,715 new cases were documented in badly hit 62 districts while the count was 178 657 cases in these areas in August 2022[14].Age ranged from 13 years to 85 years with mean age of 26.6 years.Majority of patients belong from younger age group.In a Pakistani study author urges importance of age in the occurrence of malaria and stated younger age groups were more prone for malaria[1].Although P. vivax ratio is supposed to be more common in males[9]but in our study females were predominant with 52%.This is not very astonishing as some other authors also register the female predominance.Very scanty literature is available from Pakistan regarding severe vivax malaria.Study byZubairi et  al.,although old but worth mentioning as they assessed severe malaria cases.They noticed that 79.9% of cases of severe malaria were due to P. vivax[15].Once thought to be benign disease increasingly being recognized as cause of severe malaria percentage of these cases was 24.1% in 2009 to43.2% and 39.5% in 2011 [16].We noted that 50.6% patients suffered from severe vivax malaria.In comparison to this an Indian author study also highlight approximately 50% of severe vivax malaria.This was comparable to a study byMathews et al., from India they found 42% severe