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Programme Partnership Arrangement

Lessons from Beyond Garki and similar studies in Ethiopia

Copyright Malaria ConsortiumMalaria incidence has been declining in Ethiopia over the past decade. A deeper understanding of the features of the disease and possible determinants of the trends is essential to adapt interventions and maintain cost-effectiveness and equity.

Beyond Garki surveys were implemented in Ethiopia between 2012 and 2014 to collect data on malaria prevalence, vectors, determinants of transmission, treatment-seeking behaviour, and coverage and use of control measures in two sites in South Nations, Nationalities and Peoples (SNNP) Region. The results were presented and discussed at a workshop held in Hawassa in January 2016. Findings from other studies were also presented by partners from various organisations. More than 60 participants from nearly 30 different organisations or stakeholders/partners discussed the findings, identified challenges and gaps and formulated recommendations to strengthen efforts towards malaria elimination in Ethiopia.

The workshop was opened by Mr Habtamu Beyene, Deputy Head of the SNNP Regional Health Bureau, who stressed that the findings and recommendations will be considered in the Health Sector Transformation Plan, and expressed his gratitude to UK aid, Malaria Consortium and the Beyond Garki research team for the impressive accomplishment and for providing financial and technical support to this important work. Earlier, Mr Dereje Dilu, representing the Federal Ministry of Health, described the importance of the research and the workshop in informing the malaria control and elimination strategy of the country.

Beyond Garki Ethiopia

Dr Tarekegn Abeku and Irene Kyomuhangi of Malaria Consortium presented results of Beyond Garki project. Both Ethiopia sites had low malaria prevalence rates throughout the study period. Overall, the average prevalence rates were 1.0% and 0.5% in the two sites –Hembecho in Boloso Sore District and Guba in Halaba Special District – during peak transmission, respectively. Plasmodium vivax was the most common cause of infection, followed by P. falciparum. Prevalence declined steadily during 2012-2014.

Coverage and use of insecticide treated nets (ITNs) was low in one of the sites (Guba) but was high in the Hembecho although still short of the required levels. ITN use rates among those with access were significantly more than general use rates, indicating that ownership is an important determinant of use. Nets being too old or dirty were often mentioned as reasons for not using nets.

The benefit of using ITNs was investigated by comparing malaria infection rates in individuals who slept under an ITN the previous night and those who did not. In both Uganda sites, individuals who used ITNs had significantly lower infection compared to those who did not use the nets. In the Ethiopia sites, the difference was not significant probably due to low prevalence rates.

There was decline in percentage of children who received antimalarials over time indicating reduced incidence. Among children for whom treatment was sought, the majority of cases (57-100%) received a diagnostic test. The majority of children with malaria were given appropriate antimalarials.

Other studies

Vector behaviour and insecticide resistance

Dr Meshesha Balkew, Aklilu Lemma Institute of Pathobiology, Addis Ababa University, presented results of an entomological study in Zway area (Oromia Region). Anopheles arabiensis, An. pharoensis, An. zeimanni and An. funestus s.l. were collected. The peak indoor and outdoor biting for An. arabiensis was between 20.00 and 22.00h. An. arabiensis was susceptible to carbamates but resistant to pyrethroids. Metabolic resistance was partly responsible for the observed pyrethroid resistance. Both An. arabiensis and An. pharoensis were fully susceptible to the larvicide temephos.

Dr Josephat Shililu of Abt Associates presented results from entomological monitoring within the PMI Africa Indoor Residual Spraying Project. An. gambiae s.l., An. pharoensis and An. coustani s.l. were collected in similar proportions. A higher number of host-seeking An. gambiae s.l. were collected outdoors in two intervention sites as compared to indoors. An. gambiae s.l. was susceptible to pirimiphos-methyl, fenitrothion and propoxur, but was resistant to DDT and pyrethroids in all sites. Resistance was also detected against bendiocarb and malathion in some but not all sites. The kdr L1014F mutation in An. arabiensis ranged from 13% to 100%.

Diagnosis and treatment of malaria in Ethiopia

Dr Samuel Girma, Columbia University, ICAP in Ethiopia, presented the existing guidelines for malaria diagnosis and case management at different levels, treatment failure and its management, chemoprophylaxis, management of severe malaria, treatment of malaria during pregnancy and issues under discussion for revision. Some of the points under discussion for revision include use of a single dose primaquine as a gametocytocidal drug for P. falciparum and weekly prophylaxis with chloroquine for pregnant women infected with P. vivax to prevent relapse during the rest of the pregnancy.

Malaria epidemiology and surveillance

Dr Adugna Woyessa, Ethiopia Public Health Institute, presented trends in malaria epidemiology in Ethiopia and discussed the pros and cons of various epidemiological data collection methods. HMIS data collection and reporting requires substantial improvement in Ethiopia to strengthen surveillance and appropriate targeting of interventions.

An evaluation of a mobile phone-based malaria routine surveillance system in Amhara Region was presented by Mr Asefaw Getachew, MACEPA/PATH. A rapid reporting system was established in catchment areas of health posts in eight districts. Community-based surveillance assistants were trained and deployed to report weekly morbidity and commodity data using mobile phones supported by the web-based DHIS2 platform. The system has a potential to improve timeliness, accuracy and completeness of data on morbidity and essential stocks.

Updates on malaria elimination strategy development

Dr Hailemariam Lemma, CHAI, presented updates of the malaria elimination strategy development. The strategy is based on stratification of areas according to annual parasite incidence (API). Initially, districts in the low transmission stratum are primarily targeted for elimination. There will be four elimination phases: optimisation, pre-elimination, elimination, and prevention of re-introduction. The malarious districts of the country will be grouped and each will progress through the various phases at different time periods according to set priorities.

A brief summary of some of the recommendations

  • Use effective behavioural change communication to increase ITN use rates.
  • Review the stratification strategy below the district level for more accuracy and for proper targeting of IRS, and determine appropriate timing based on local transmission factors and seasonality of vector abundance.
  • Finalise and implement the Insecticide Resistance Monitoring and Management strategy.
  • Set collaborative research agenda and work out a system of coordination of operational research and develop platforms for sharing data and tools.
  • Standardise pre-service and in-service training of laboratory and clinical staff to improve malaria diagnosis and disease management, and strengthen external quality assurance and clinical audits.
  • Establish a system for a pre-import assessment of the quality of anti-malaria commodities.

Learn more about the Beyond Garki project by visiting the microsite.


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