Assessment of hematological parameters in malarial suspected patients: Cross sectional study

Background Malaria is a Zoonotic disease, worldwide in distribution and caused by different species of plasmodium. It is a major cause of sickness and mortality in developing countries including Pakistan. This study was carried with the aim to find out the prevalence of malaria and to aware the people about this disease. Methods The study was carried out in district charsadda. 120 blood samples were collected from suspects both male and female, during the period of March 2022 to September 2022 and were analyzed for CBC and for Microscopic examination. Results Out of these 120 samples 12(10%) were found positive and 108(90%) were negative. The prevalence of malaria was more in the month of June and July. The infection was high in male (13.3%) as compared to female (6.6%). The prevalence was more in rural areas 8(13.3%) than in urban areas 4(6.6%). Conclusion The Hemoglobin, Hematocrit, Platelets and Red Blood Cells were found more affected in positive samples as compared to other parameters. The present study will help the malarial control programs to focus on rural areas. The Plasmodium vivax is more common in the study area.


Introduction
Malaria, a name coined by Italians in 1753, comes from the Italian words 'mala' (bad) \and 'aria' (air), reflecting the belief that the disease was caused by noxious fumes from marshy terrain (Boucher et al., 2018).The roots of malaria can be traced back to the earliest civilizations, as evidenced by descriptions of the disease in ancient Chinese medical texts dating to 2700 BCE, as well as the Ebers Papyrus from roughly 1500 BCE (Cox, 2010).As the foremost parasitic infection on the planet, malaria poses a major challenge to global health, with developing countries like Pakistan bearing the brunt of its impact in terms of illness and death (Khan et al., 2018).Malaria is a serious infectious disease that easily spreads through populations, with cerebral malaria, caused primarily by P. falciparum, representing the most perilous form of the disease that can lead to a life-threatening complications (khan et al., 2013).Traditionally, four Plasmodium species P. falciparum, P. vivax, P. ovale, and P. malariae have been recognized as the culprits behind human malaria infections, but there is now evidence that P. knowlesi, which normally affects macaque monkeys, can also infect humans (Collins, 2012).(See Tables 1-4.) Among the six Eastern Mediterranean nations with high malaria transmission rates, Pakistan stands out as a country where virtually the entire population is at risk of contracting the disease.The prevalence of malaria, however, varies across different provinces and cities due to the diversity of climates (WHO, 2019).In 2017, the cumulative Annual Parasite Index (API) for Pakistan was 1.88, with the highest incidence of malaria reported in Khyber Pakhtunkhwa (30%), followed by Sindh (26.5%),Federally Administered Tribal Areas (FATA) (21.9%),Baluchistan (20.5%) and Punjab reported the lowest number of cases i.e., 1.1% (Qureshi et al., 2019).

Materials and methods
The present study was completed in a period of 7 months (March 2022 to September 2022).A total of 120 blood samples were collected from just symptomatic individuals and a proper questionnaire filled from each individual.The samples were collected at DHQ hospital Charsadda and DHQ Hospital Tangi Charsadda.Three ml of blood was drawn from each suspected person by using a sterilized syringe and transform into EDTA tube.The blood was then analyzed for CBC and Microscopic examination.

Results
A total of 120 blood samples were collected from only symptomatic patients at district Charsadda and this blood is tested through microscopy in laboratory.The data is also collected through proper questionnaire.Out of these 120 blood samples 12 samples were positive and 108 samples were negative.In this study hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, platelets count, red blood cells count were determined by using hematology analyzer.
Out of 120 blood samples, 60 samples were taken from male and 60 from female.Out 60 males 8(13.3%)samples were found positive and 52(86.7%)were negative and out of 60 females 4(6.6%) samples were found positive and 56(93.4%)were negative.Age wise prevalence was also detected in the people of different age groups in district Charsadda.Total 23 samples were collected from age group 1-20 years out of 23 samples 1 (4.3%) were positive and in age group 21-40 years total 46 samples were collected in which 7(15.2%) were found positive while in age group 41-60 years out of 37 samples 3(8.1%) were positive.The samples collected from age group 61-80 years were 14 in which 1(7.1%) were found positive.
T. Khan et al.

Month wise prevalence of malaria in district Charsadda
Month wise data is collected from march2022 to September 2022.A highest number of malaria cases were found in June and July while the lowest number found in March.

Hematological parameter and WHO value
The criteria for diagnosing anemia based on hemoglobin levels were 12 g/dl for females and 13 g/dl for males.Abnormal hematocrit values is below from 36% for females and below 41% for males.Normal RBC counts for males ranged from 4.2 to 5.8 × 10 6 / cmm, while for females they ranged from 3.6 to 5.6 × 10 6 /cmm.Anemia was indicated by RBC indices below MCV < 80 fl and MCH < 32 g/dl.Similarly, platelet counts below 150 × 10 3 /cmm were considered abnormal.After comparing the hematological profile of MPpositive patients with WHO values, the results were obtained.

Male Hematological
Detected Males Total

Gender wise hematological changes
A total of 120 samples were collected from district Charsadda out of which 12 samples were found positive while 108 samples were negative.The positive samples were analyzed for hematological changes.MP-Positive male and female patient were have different hematological profile.

Male hematological changes
In male MP patients the hematology is effected like hemoglobin, hematocrit, red blood cells and platelets is below from the WHO value while the mean corpuscular hemoglobin concentration is not effected.

Female hematological changes
In female malarial patients the hemoglobin, red blood cells, hematocrit is affected while mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration is normal.

Discussions
Malaria is one of the major health problems and predominant of all parasitic infections in the world and is a major cause of sickness and mortality in developing countries with inclusion of Pakistan (Shah et al., 2016).According to the WHO 97% (approximately 150 million) of the Pakistani population is at risk of malaria, the transmission season is from September to November but high risk of malaria in KP is in the month of July and August (Khatoon et al., 2010).Malaria is usually associated with various degrees of reduced blood counts, and mild to moderate thrombocytopenia is a common association of malaria but it is rarely associated with hemorrhagic manifestations or a component of disseminated intravascular coagulation (Khattak et al., 2013).This survey was conducted from March 2022 to September 2022 to provide information on malaria prevalence in district Charsadda to find out the distribution of malaria in the people of district Charsadda.For this purpose a total of 120 blood samples were collected from district charsadda and this blood is tested through microscopy in laboratory.The data is also collected through proper questionnaire.Out of these 120 blood samples only 12(10%) samples were positive and 108(90%) samples are negative.These results is contrast with other provinces of Pakistan like Punjab province is very low; the prevalence ranged from 1.7% in Lahore to 5.5% in Bhakkar district.This stark divergence in prevalence rates can be attributed to the exceptional level of vigilance and care demonstrated by the residents of these cities, which serves to significantly mitigate the positivity rates.Sindh province reported increases in malaria prevalence in all areas, while Baluchistan province also reported an increase in the prevalence, The surge in malaria prevalence in Sindh and Baluchistan can be attributed to a lack of public awareness and adherence to preventive measures, as many people in the region are not taking adequate  Female Hematological Changes Detected Females Total Females precautions and remain unaware of the disease's potential transmission 1990s (Rowland et al., 2002;Ladhani et al., 2002).
According to present study, 75% of cases have low Hb level.These result are in good agreement with WHO criteria.According to WHO 77% of our patients were anemic with regard to Hb values.Similarly, a study from Uganda had shown 76% prevalence of malaria parasitemia among severely anemic hospitalized patients in malaria endemic region.According to (Srichaikul, 1999), Anemia is one of the most common complications in malaria.The incidence of anemia in malaria was reported to be as high as 80%.These studies are in concordance with this study.The Present study show that 12-25% of cases are associated with thrombocytopenia as compared to much higher frequencies like 34.4% and 34% (Tan et al., 2008).
The Present study shows 50% cases with low RBC count in both male and female which is in accordance to 50.8% in P. vivax (Agravat and Dhruva, 2010).Anemia can be attributed to the destruction of red blood cell, splenic removal of parasitized and nonparasitized RBCs and dyserthropoiesis and engulfment in reticulo-endothelial system (Makani et al., 2011).
The effect of malaria on MCV, MCH, MCHC was no or little which is related with study performed by (Sirak et al., 2016).According to (Kotepui et al., 2014) HCT, MCV and MCHC were found significantly increased in malaria infected patients than that of controls in a study conducted in Thailand Myanmar border.Hematological parameters in this study were used to determine anemia induced by malarial parasitic infestation.

Conclusion
The Present study shows that P. vivax is more common in the study area as compared to other species.In present study the malaria infection is more in male as compared to female because male mostly have more outdoor activities as compare to female and also they do works in marshy places.The prevalence of malaria is more in rural area as compare to urban area because in rural areas most people don't have such money to afford expensive mosquito sprays or repellents.The hematological parameters is more effected in female as compared to male.The prevalence of malaria in the month of June and July is more as compared to other months because the summer season begins so most people start their outdoor activities and its suitable time for mosquito to bite person easily as compare to winter season. Recommendations: • Houses are sprayed before the season of greatest infection.This prevents malaria from being spread.
• Draining areas that could be used the breeding grounds.
• To educate people about Prevention, Risk factors through seminar, pamphlet, radio, media, newspaper etc.

Table 1
Age wise prevalence of Malaria.

Table 2
Hematological parameter and WHO value.

Table 3
Male Hematological Changes.

Table 4
Female Hematological Changes.