Malaria
in Different Regions in the Kingdom of Saudi Arabia during the Year 2018

Anas Siraj Dablool, Alashary Adam Eisa
Hamdoon

Department of public health, College of
health sciences at Al Leith, Umm Al-Qura University, Kingdom of Saudi Arabia.

[email-masked]

Abstract: The
risk of acquisition of malaria in Saudi Arabia is limited to the Southwestern
part of the country, with the highest number of cases reported from Gizan and
Aseer regions. The Eastern Province of Saudi Arabia is free of local
transmission of malaria since 1978. The lack of transmission of malaria in this
province is related to the malaria control program that was set in place in
1948 (Al-Tawfifiq, 2006). The present article searched Saudi Ministry of Health
reports, data was obtained from Open Data Portal (https://data.gov.sa/Data/en/organizaton/ministry_0f_health) is the data that can be freely used, re-used, and
redistributed by anyone without any technical, financial or legal restriction.
The collected data included notified malaria cases and malaria parasites
species in twenty Regions which were: Riyadh, Makkah, Jeddah, Ta`if, Medinah,
Eastern, Al-Ahsa, Hafr Al-Baten, Qaseem, Aseer, Bishah, Tabouk, Ha`il,
Northern, Jazan, Najran, Al-Bahah, Al-Jouf, Qurayyat and Qunfudah. This article
aimed to determine the malaria prevalence and species of Plasmodium causing the
disease in different regions in the Kingdom of Saudi Arabia during the year
2018. Saudi Ministry of Health reported that malaria parasites were notified
from 19 regions. Four malaria parasites species were reported: Plasmodium
falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium
malaria. Out of 1015953 examined persons positive cases of malaria were
found 2710, of which 1908 (0.19%) were a malignant malaria (Plasmodium
falciparum), 802 (0.08%) were Benign Tertiary (Plasmodium vivax and Plasmodium
ovale) and one case (0.00009%) were a Quartan (Plasmodium malaria).
For Plasmodium falciparum, high number of cases were reported in Jazan
(n = 1358), Jeddah (n = 118) and Eastern region (n = 101). For Plasmodium
vivax and Plasmodium ovale, high number of cases were reported in
Eastern (n = 208), Jazan (n = 158), Riyadh (n = 97) and Jeddah (n = 97). The
prevalence of malaria in this study was found 0.27.

[Dablool
A  Siraj, Hamdoon A Eisa. Malaria in Different Regions in the Kingdom
of Saudi Arabia during the Year 2018. Life Sci J 2021;18(9):7-14] ISSN 1097-8135 (print); ISSN 2372-613X (online) http://www.lifesciencesite.com. 2. doi:10.7537/marslsj180921.02.

Keywords: Prevalence;
Malaria parasites; Distribution; Malignant malaria; Jazan

1. Introduction

Malaria is endemic in 109 countries,
spanning all continents, with the exception of Australia and Antarctica.
Approximately 300 million people are affected by malaria resulting in the
deaths of 1–1.5 million people every year (Sami et al., 2017).
About 3.2 billion people almost half of the world’s populations are at
risk of malaria (Khalifa et al., 2017). Every year, 10.5 million cases
and 49,000 deaths are reported in the Eastern Mediterranean region alone (Sami et
al., 2017). In the Kingdom of Saudi Arabia, malaria is known to exist and
had been documented in pre-Islamic Arabic writings (Annobil et al.,
1994). Malaria endemicity is localized to the Southwestern part of the country,
with the highest number of cases reported from Jazan and Aseer regions
(Al-Tawfifiq, 2006; Alkhalife, 2003; Bashawri et al., 2001). Malaria
transmission still occurs in the north, western and especially endemic in
lowlands of Aseer Region. Its existence is perpetuated there by continuous
importation from Yemen. Besides there was a high threat of introducing malaria
by pilgrims during Hajj and Umrah studies also indicate a risk of malaria
transmission by blood transfusion (Jamjoom et al., 2006). However there
has been no local transmission in the Eastern Province since 1978 as a result
of control programs that were initiated, as early as 1948 (Al-Tawfifiq, 2006;
Bashawri et al., 2001). Saudi nationals' resident in Riyadh could also
get exposed to malaria during visits to endemic areas or during travel to
endemic areas within the Kingdom of Saudi Arabia (Alkhalife, 2003). Studies
conducted in 2001 and 2006 indicated that the eastern province of Saudi Arabia
is free of indigenous malaria transmission (Sami et al., 2017). In
Al-Baha Province, although no malaria cases have been reported recently, the
presence of competent mosquito vectors increase the potentiality of malaria
transmission (Alahmed et al., 2015), Saudi Ministry of Health reported
in 2006 reported that 57.8% of local cases were in Jazan, 36.7% in Aseer, 3% in
Al Medinah, and 1.2% for each of Makkah and Qunfudah. The highest percentage of
cases recorded among foreigners was in Jazan (54.3%), followed by the Eastern
region (13.5%) and Jeddah (6.4%). There is always a high risk of introducing
malaria by pilgrims (Al-Harthi and Jamjoom, 2008). In 2009,
out of 2333 reported malaria cases, only 58 (1.7%) were local cases, the rest
were imported. In the Eastern Province, out of 700 malaria cases in year 2011,
99.1% were imported and only 0.9% was from Saudi citizens. Most local
infections occur in the South-western regions of Jazan and Aseer, and the
predominant species is Plasmodium falciparum. Imported cases came from
the neighboring countries of Yemen and Sudan and the Indian subcontinent. Yemenites
and Sudanese predominantly carry Plasmodium falciparum, while travellers
from India and Pakistan are infected with Plasmodium vivax alone or in
co-infection with Plasmodium falciparum (Nzila and Al-Zahrani, 2013).
Recent findings indicate that Plasmodium vivax is also responsible for
cerebral malaria, acute kidney injury, liver dysfunction, severe respiratory
distress, abnormal bleeding, severe anaemia and multiple organ failure (Khan et al., 2014). In 2013, the Saudi Ministry
of Health reported 2513 cases nationally, most of which occurred in the Jazan
region. The Jazan area is known for hyper endemic transmission of malaria due
to continuous importation of cases from Yemen (Sami et al., 2017). Mass
blood surveys sampling 91,676 people across the Jazan region between 2012 and
2014, found only three infections (0.003%), all of which were imported from
Yemen (Al Zahrani et al., 2018). In 2015 report that out of 1,306,700
examined cases positive cases of malaria were 2620 (0.20%) , of which 1444 were
a malignant malaria (Plasmodium falciparum), 1164 were a benign tertiary
(Plasmodium vivax and Plasmodium ovale), 10 were a Quartan and 2
were a mixed (Khalifa et al.,
2017). Ministry of Health in 2016 in Kingdom Saudi
Arabia found that of 1,267,933 examined cases positive cases of malaria were
5,382 (0.42%) , of which 3,922 were a malignant malaria (Plasmodium
falciparum), 1,420 were a benign tertiary (Plasmodium vivax and Plasmodium
ovale ) and 40 were a Quartan (Al-Harthi
and Jamjoom, 2008). Plasmodium falciparum is the
predominant parasite strain causing malaria in Saudi Arabia and Yemen (Sami et al., 2017).
Malaria is the one of the major health concerns, endemic in the lowland of
Aseer region in the south western province and sporadic cases were reported in
another region. Jazan region and the bordering of Yemen were classified as the
most malarious parts in Saudi Arabia. Malaria was perpetuated there-by
continuous importation, from Yemen (Nzila and Al-Zahrani, 2013). Malaria
incidence in Saudi Arabia is relatively low and is represented along the South
region of the Red Sea coast to the down border of Yemen where malaria is hyper
endemic still have a high prevalence (Safia
et al., 2018; Sami et al., 2017). The border spans
1326 km from the Red Sea to the border triangle with Oman. The most densely
populated area is toward the Red Sea, including Jazan and Asir regions in Saudi
Arabia, which share a 330 km land border with Yemen, and represent the last
remaining foci of malaria transmission in Saudi Arabia. Conversely, malaria
transmission in Yemeni Governorates that border Jazan and Asir remains
persistently endemic despite some progress toward control prior to 2014 (Al
Zahrani et al., 2018).

In
the Kingdom of Saudi Arabia, an extensive effort, started in the 1940s, has led
to a substantial decrease of malaria cases in many parts of the country. In the
Eastern and Northern provinces for instance, malaria has been eliminated since
no local transmission has been observed for many years. Most cases are imported
malaria, through emigrants who form the workforce in the country (Nzila
and Al-Zahrani, 2013). In 1963, Saudi
Arabia signed a pre-eradication program plan with the World Health Organization
and started the destruction of reservoir of infection, public health education,
large-scale vector control (by spraying residential houses with
dichlorodiphenyltrichloroethane) in hyperendemic areas, weekly application of
larvicides, ultra–low-volume space spraying, prompt treatment of malaria
cases, and training of health workers on the control and management of malaria (Memish et al., 2014).

The
primary vector for malaria transmission is Anopheles arabiensis (Alshahrani et al., 2016),
prevalent mostly in the southwestern part of Saudi Arabia at altitudes below
2,000 meters. Secondary vectors include A. sergentii, A. stephensi,
A. superpictus, and A. multicolor (World Health
Organization, 2015). The following species of Anopheles mosquitoes
recorded as primary malaria vector in Kingdom of Saudi Arabia: A. gambiae (Southern
part), A. sergentii (Western region), A. stephensi (Eastern
region) and A. superpictus (Northern region). In addition to the four
mentioned species, the following Anopheles have been reported in the country: A.
cinereus (Abha, Asir Regions), A. dthali (Western and Madinah
region), A. fluviatilis (Eastern Region), A. multicolor (Eastern,
Western and Madinah Regions), A. pharoensis (Tabuk region), A.
pretoriensis (Jazan Region), A. pulcherrimus (Eastern Region), A.
rhodesiensis (Yanbu in Madinah Regions), A. turkhudi (Western and
Madinah regions), A. coustani and A. tenebrosus (Eastern Region).
None of these species have yet been incriminated in malaria transmission in
Kingdom of Saudi Arabia. Previous studies only stated the importance of A.
gambiae as a potential malaria vector in the Tihama. Also, recent studies
revealed that A. arabiensis is the most important malaria vector in
Jazan region (Waheed et
al., 2018) A total of 15 Anopheles species have been recorded, five of
which are known to be competent malaria vectors: A. arabiensis, A.
sergentii, A. stephensi, A. superpictus and A.
culicifacies. A. arabiensis is currently the only known vector of
malaria in Saudi Arabia (Michael et al., 2014). The
present article aimed to determine the malaria prevalence and species of
Plasmodium causing the disease in different regions in the Kingdom of Saudi
Arabia during the year 2018.

2. Material and Methods

The
present article searched Saudi Ministry of Health reports, data was obtained
from Open Data Portal(https://data.gov.sa/Data/en/organizaton/ministry_0f_health) is the
data that can be freely used, re-used, and redistributed by anyone without any
technical, financial or legal restriction. The collected data included notified
malaria cases and malaria parasites species in twenty Regions which were:
Riyadh, Makkah, Jeddah, Ta`if, Medinah, Eastern, Al-Ahsa, Hafr Al-Baten,
Qaseem, Aseer, Bishah, Tabouk, Ha`il, Northern, Jazan, Najran, Al-Bahah,
Al-Jouf, Qurayyat and Qunfudah. This article aimed to determine the malaria
prevalence and species of Plasmodium causing the disease in different regions
in the Kingdom of Saudi Arabia during the year 2018. Laboratory confirmation is
obtained by demonstration of malaria parasites in blood films (thick and thin
film). This remains the gold standard method for the diagnosis, identification
of Plasmodium species and estimation of parasite load (density). Parasite
density is quantified by counting ≥ 200 WBC and expressed as number of
parasites per 200 WBC or converted to number of parasites per microliter.
Giemsa stain is recommended for identification of Plasmodium species and for
parasite count. It used in all health facilities throughout the Kingdom (Malaria Elimination Program. National Malaria Drug
Policy, 2018). Data
were analyzed by Microsoft Office Excel, 2007.

3. Results

Ministry
of Health in 2018 in Kingdom of Saudi Arabia found that of 1015953 examined
persons positive cases of malaria were 2710, of which 1908 (0.19%) were a
malignant malaria (Plasmodium falciparum), 802 (0.08%) were Benign
Tertiary (Plasmodium vivax and Plasmodium ovale) and one case
(0.00009%) were a Quartan (Plasmodium malaria).  (Table 1) shows malaria parasites species
and malaria prevalence. (Fig. 1) shows
notified malaria cases by region in 2018, high number of malaria cases were
reported from Jazan (n = 1516) and Eastern (n = 309). (Fig. 2) shows the occurrence of Plasmodium
falciparum, high
number of cases were notified in Jazan
(n = 1358), Jeddah (n = 118) and Eastern (n = 101) regions. (Fig. 3) shows the occurrence of Plasmodium vivax and Plasmodium
ovale, high
number of cases were notified in Eastern
(n = 208), Jazan (n = 158), Riyadh (n = 97) and Jeddah (n = 97). (Table 2) shows monthly notified malaria cases
in endemic zones in 2018 the high number of cases from Jazan (n = 1516) and
Jeddah (n = 215). (Table 3) showed the prevalence of malarial in different
regions in Kingdom of Saudi Arabia study was conducted by Khalifa et al.,
2017.

Figure 1. Notified Malaria Cases by Region of the
Saudi Arabia, 2018

Figure 2. Occurrence of Plasmodium falciparum
in Saudi Arabia, 2018

Figure 3. Occurrence of Plasmodium vivax and Plasmodium
ovale in Saudi Arabia, 2018

Table 1. Prevalence of malaria by Regions of the Saudi
Arabia, 2018

Regions

Number of examined persons

Number of positive cases

Prevalence

P. falciparum
(Malignant)

P. vivax and P.ovale
(Benign Tertiary)

P. malariae
(Benign Quartan)

Riyadh

209823

54

97

1

0.072

Makkah

21386

37

30

0

0.31

Jeddah

6249

118

97

0

3.4

Ta`if

82897

21

34

0

0.066

Medinah

72347

90

40

0

0.18

Eastern

215322

101

208

0

0.14

Al-Ahsa

52203

13

8

0

0.04

Hafr Al-Baten

96

9

10

0

19

Qaseem

54398

10

49

0

0.11

Aseer

23322

34

29

0

0.27

Bishah

3357

13

7

0

0.59

Tabouk

9061

3

0

0

0.033

Ha`il

5767

5

5

0

0.17

Northern

1172

6

2

0

0.68

Jazan

184734

1358

158

0

0.82

Najran

22403

15

14

0

0.13

Al-Bahah

15804

8

4

0

0.075

Al-Jouf

26742

0

4

0

0.015

Qurayyat

7178

0

0

0

0

Qunfudah

1692

13

6

0

1.12

Total

1015953

1908

802

1

0.27

Table 2. Notified Malaria Cases in Endemic Zones, 2018

Region

Jan.

Feb.

Mar.

Apr.

May

June

July

Aug.

Sep.

Oct.

Nov.

Dec.

Total

Makkah

1

4

2

6

3

0

7

28

6

6

2

3

67

Jeddah

19

15

11

11

11

6

8

16

23

36

37

22

215

Medinah

9

2

6

7

1

5

13

42

18

20

4

3

130

Aseer

3

5

4

1

5

4

11

2

0

11

11

6

63

Jazan

93

219

241

115

17

52

17

9

21

39

245

448

1516

Al-Bahah

0

2

0

0

0

0

0

1

2

5

1

1

12

Qunfudah

0

1

1

1

0

0

1

3

5

5

1

1

19

Total

125

248

265

141

37

67

57

101

74

122

301

484

2022

Table 3. The prevalence of malarial cases in different
regions in Kingdom of Saudi Arabia

Years

examined
cases

Malaria
cases

Prevalence

2013

1,309,783

2513

0.19%

2014

1,249,752

2,305

0.18%

2015

1,306,700

2620

0.20%

2016

1,267,933

5,382

0.42%

Source, Khalifa et al., 2017

4. Discussions

In the
present article four malaria parasites species were notified: Plasmodium
falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium
malaria. The major cause of malaria was found Plasmodium falciparum, Sami
et al., (2017) mentioned that the Plasmodium falciparum
is the predominant parasite strain causing malaria in Saudi Arabia and Yemen.
Khalifa et al., (2007) reported that in year (2015) out of 1,306,700
examined cases positive cases of malaria were 2620 (0.20%), of which 1444 were
a malignant malaria (Plasmodium falciparum), 1164 were a benign tertiary
(Plasmodium vivax and Plasmodium ovale), 10 were a Quartan and 2
were a mixed (Khalifa et al.,
2017). Ministry of Health in (2016) in Kingdom Saudi
Arabia found that of 1,267,933 examined cases positive cases of malaria were
5,382 (0.42%), of which 3,922 were a malignant malaria (Plasmodium
falciparum), 1,420 were a benign tertiary (Plasmodium vivax and Plasmodium
ovale) and 40 were a Quartan (Al-Harthi
and Jamjoom, 2008). This article has
shown that high
numbers of cases infected with Plasmodium falciparum were notified from Jazan,
Jeddah and Eastern region. Whereas
for the Plasmodium vivax and Plasmodium
ovale, the high
number of cases were reported in Eastern
region, Jazan, Riyadh and Jeddah these results agree with observations of previous
studies conducted by Al-Tawfifiq (2006), Alkhalife (2003) and Bashawri et al.,
(2001). In 2013, the Saudi Ministry of Health reported 2513 cases nationally,
most of which occurred in the Jazan region. The Jazan area is known for hyper
endemic transmission of malaria due to continuous importation of cases from
Yemen (Sami et al., 2017). Al
Zahrani et al., (2018) indicated that mass blood surveys sampling 91,676
people across the Jazan region between 2012 and 2014, found only three
infections (0.003%), all of which were imported from Yemen (Al Zahrani et al.,
2018). Jamjoom et al., (2006) stated that malaria
transmission still occurs in the north, western and especially endemic in
lowlands of Aseer Region. Its existence is perpetuated there by continuous
importation from Yemen. There was a high threat of introducing malaria by
pilgrims during Hajj and Umrah. Observations of previous studies stated
there was no local transmission in the Eastern Province since 1978 as a result
of control programs that were initiated, as early as 1948 (Al-Tawfifiq, 2006; Bashawri et al., 2001). The
prevalence of malarial in different regions in Kingdom of Saudi Arabia in
present article was found 0.27% it is low when compared with malaria prevalence
in the year (2016), 0.42% study conducted by Khalifa et al., (2017) and
high than malaria prevalence in the year (2013) (0.19%), year (2014) (0.18%)
and year (2015) (0.20%). Malaria incidence in Saudi Arabia is relatively low
and is represented along the South region of the Red Sea coast to the down
border of Yemen where malaria is hyper endemic still have a high prevalence (Safia et al., 2018; Sami et al., 2017).
Limitations of this article include used of open access data which contained
information on notified malaria cases and regions which makes it difficult to
determine any causative relationship. Nevertheless, this was a strategic
approach to assess the baseline information regarding malaria prevalence and
distribution.

Acknowledgements:

We
would like to thank Saudi Ministry of Health for their providing us with
information and data on the open portal and made it available for researchers.

Corresponding Author:

Dr. Anas Siraj
Dablool

Department of public
health

College of health sciences
at Al Leith

Umm Al-Qura
University, Kingdom of Saudi Arabia.

E-mail: [email-masked]

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