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Background: Identifying areas that support high malaria risks and where populations lack access to health care is central to reducing the burden in Afghanistan. This study investigated the incidence of Plasmodium vivax and Plasmodium falciparum using routine data to help focus malaria interventions. Methods: To estimate incidence, the study modelled utilisation of the public health sector using fever treatment data from the 2012 national Malaria Indicator Survey. A probabilistic measure of attendance was applied to population density metrics to define the proportion of the population within catchment of a public health facility. Malaria data were used in a Bayesian spatio-temporal conditional-autoregressive model with ecological or environmental covariates, to examine the spatial and temporal variation of incidence. Findings: From the analysis of healthcare utilisation, over 80% of the population was within 2 hours’ travel of the nearest public health facility, while 64.4% were within 30 minutes’ travel. The mean incidence of P. vivax in 2009 was 5.4 (95% Crl 3.2-9.2) cases per 1000 population compared to 1.2 (95% Crl 0.4-2.9) cases per 1000 population for P. falciparum. P. vivax peaked in August while P. falciparum peaked in November. 32% of the estimated 30.5 million people lived in regions where annual incidence was at least 1 case per 1,000 population of P. vivax; 23.7% of the population lived in areas where annual P. falciparum case incidence was at least 1 per 1000. Conclusion: This study showed how routine data can be combined with household survey data to model malaria incidence. The incidence of both P. vivax and P. falciparum in Afghanistan remain low but the co-distribution of both parasites and the lag in their peak season provides challenges to malaria control in Afghanistan. Future improved case definition to determine levels of imported risks may be useful for the elimination ambitions in Afghanistan. © 2014 Alegana et al.
Afghanistan is divided into 34 administrative provinces. Healthcare is delivered mainly through the Basic Package for Health Services (BPHS) and the Essential Package for Hospital Services (EPHS) constituted in 2002 by the Ministry of Public Health (MoPH) [20], [21], [22]. In a bid to increase coverage, the BPHS was expanded through the contracting out of services to NGOs and MoPH partners [21], [23]. The BHC constitutes clinics, health posts and Maternal Child Health (MCH) centres and Comprehensive Health Centres (CHC). This is linked to EPHS made up of the District Hospitals (DH) (first referral level) and regional or provincial (tertiary) hospitals. At village level community health workers manage the health posts and treat mild conditions and, in some cases, Mobile Health Teams (MHTs) are used [20], [24]. In terms of data reports, tally sheets are filled at these lower-tier facilities and aggregated at the next tier facilities (CHC) which are then forwarded to regional directorates [16]. Thus, the health posts serve as a support network for the health centres and sometimes malaria cases are reported at the health centre rather than the individual health unit. The basic health centres link the basic service providers at the community level with the next service tier (the CHC) that are, in turn, linked to district hospitals and regional referral hospitals. Thus, where no regional or tertiary facility exists, district hospitals are the main referral centres. HMIS reports are also compiled the regional level and distributed to the national management level. Inpatient facilities are provided mainly at the tertiary level [20]. Parasitological diagnosis is conducted at higher tier facilities (Hospitals) where laboratory facilities exist while clinical diagnosis is predominantly used at health posts. The 2010 national malaria treatment guidelines outline the scale up of diagnostics at all health facilities to ensure diagnosis prior to treatment. The malaria case data were obtained from HMIS through the Afghanistan National Malaria and Leishmaniasis Control Programme (NMLCP). This consisted of records from 1,629 public health facilities for a 48-month period from 2006 to 2009. Data represented aggregate monthly cases of P. falciparum and P. vivax. Of the 1,629 health facilities, 1,587 had reported malaria cases based on both clinical and parasitology examination. Parasitological diagnosis (microscopy or RDTs) was conducted at higher-tier facilities (hospitals and health centres) where laboratory facilities exist while clinical diagnosis was predominantly used at lower-level facilities such as health posts (File S1). No cases were examined or reported for 228 facilities which were treated as missing data while data for mobile units (n = 93) were omitted from the final analysis since they serve as outreach centres from major facilities. The missing spatial and temporal structures of data were imputed as ‘NAs’ and predictions made at missing locations. The spatial coordinates of health facilities were obtained from the Afghan Management Information Systems (AMIS) (http://www.aims.org.af/), which was formerly managed by the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) and the United Nations Development Programme (UNDP) in the early 2000s, but became a national independent Non-Governmental Organisation (NGO) in 2008. These facilities were either mapped using non-differential handheld global positioning systems (GPS) receivers during the assessment surveys or in some cases the longitude and latitude were established using a village or settlement database. For analysis, the facilities were classified into three broad categories that combined: basic facilities made up of health posts (HPs), clinics and maternal health centres (MCH); health centres; and hospitals. Data for modelling health care utilisation for treatment of fever was obtained from the national MIS carried out between September and October 2011 (n = 15,442 individuals)[25]. The MIS was conducted in 21 provinces, across the diverse malaria strata (medium to high risks; low risk; and very low or potentially malaria free areas) in Afghanistan, but excluded the southern regions for security reasons. A multi-stage probability sampling design was adopted in line with other MIS surveys conducted in sub-Saharan countries [26]. At the first stage clusters or villages were selected randomly in a district via probability sampling while at the second stage, households within the selected clusters were sampled randomly [25]. Self-reported treatment seeking behaviour, disaggregated by healthcare sector, was recorded for all household members that reported an episode of fever two weeks prior to the survey. A gridded population surface for Afghanistan was obtained from Asiapop at 100 m x 100 m spatial resolution (http://www.worldpop.org.uk/)[27].
