Malaria epidemiology and interventions in Ethiopia from 2001 to 2016

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malaria 102 infectiousdiseases
malathion 1 infectiousdiseasesdrugs
primaquine 4 infectiousdiseasesdrugs
pyrimethamine 1 infectiousdiseasesdrugs
sulfadoxine 1 infectiousdiseasesdrugs
AIDS 1 infectiousdiseases
infectious disease 1 infectiousdiseases

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Select Drug Character Offset Drug Term Instance
malathion 11796 insecticidal nets have been provided free in all malaria endemic areas since 2011 [[27]–[29]].DDT and malathion were the main insecticides used for IRS before 2007 (Fig. 1) [[9]]. Due to concerns of high-level resistance
primaquine 11193 first-line treatment of uncomplicated vivax malaria (Fig. 1) [[14]–[17]]. Anti-relapse therapy with primaquine for P. vivax malaria is currently recommended, with supervised use, in malaria elimination-designated
primaquine 20682 central highlands of Ethiopia where no high transmission was observed in 2016. Anti-relapse therapy with primaquine for P. vivax malaria is not currently recommended in malaria-endemic areas [[1]]. However, the national
primaquine 20915 management guidelines outline the specific recommendations, including the use of a full 14-day course of primaquine for radical cure of P. vivax at malaria elimination-designated districts and single dose primaquine
primaquine 21015 primaquine for radical cure of P. vivax at malaria elimination-designated districts and single dose primaquine for gametocytocidal activity against P. falciparum in all areas of the country [[26], [30]]. With this
pyrimethamine 6272 first line treatment of all malaria species in Ethiopia before 1998. It was replaced by sulfadoxine- pyrimethamine (SP) after 1998 for the treatment of uncomplicated P. falciparum due to widespread decline in the efficacy
sulfadoxine 6260 Chloroquine was the first line treatment of all malaria species in Ethiopia before 1998. It was replaced by sulfadoxine -pyrimethamine (SP) after 1998 for the treatment of uncomplicated P. falciparum due to widespread decline
Select Disease Character Offset Disease Term Instance
AIDS 6607 prevention and control interventions started in 2003 with the support from the Global Fund to Fight AIDS , Tuberculosis and Malaria (GFATM) [[3]]. In 2004, the FMoH introduced artemisinin-based combination
infectious disease 3131 past decade [[1]]. Ethiopia’s fight against malaria started many years ago and transmission of this infectious disease significantly decreased since 1959 [[1], [2]]. However, malaria still remains a major public health
malaria 481 African countries where Plasmodium falciparum and P. vivax co-exist. Monitoring and evaluation of current malaria transmission status is an important component of malaria control as it is a measure of the success of
malaria 538 co-exist. Monitoring and evaluation of current malaria transmission status is an important component of malaria control as it is a measure of the success of ongoing interventions and guides the planning of future
malaria 712 and guides the planning of future control and elimination efforts.Main textWe evaluated changes in malaria control policy in Ethiopia, and reviewed dynamics of country-wide confirmed and clinical malaria cases
malaria 809 in malaria control policy in Ethiopia, and reviewed dynamics of country-wide confirmed and clinical malaria cases by Plasmodium species and reported deaths for all ages and less than five years from 2001 to 2016.
malaria 997 years from 2001 to 2016. Districts level annual parasite incidence was analysed to characterize the malaria transmission stratification as implemented by the Ministry of Health. We found that Ethiopia has experienced
malaria 1175 We found that Ethiopia has experienced major changes from 2003 to 2005 and subsequent adjustment in malaria diagnosis, treatment and vector control policy. Malaria interventions have been intensified represented
malaria 1417 treated net (ITN) and indoor residual spraying (IRS) coverage, improved health services and improved malaria diagnosis. However, countrywide ITN and IRS coverages were low, with 64% ITN coverage in 2016 and IRS
malaria 1633 coverage of 92.5% in 2016 and only implemented in epidemic-prone areas of > 2500 m elevation. Clinical malaria incidence rate dropped from an average of 43.1 cases per 1000 population annually between 2001 and 2010
malaria 1997 and 2010 to 1.1 deaths per 100 000 people annually between 2011 to 2016. There was shrinkage in the malaria transmission map and high transmission is limited mainly to the western international border area. Proportion
malaria 2132 transmission is limited mainly to the western international border area. Proportion of P. falciparum malaria remained nearly unchanged from 2000 to 2016 indicating further efforts are needed to suppress transmission.ConclusionsMalaria
malaria 2355 transmission.ConclusionsMalaria morbidity and mortality have been significantly reduced in Ethiopia since 2001, however, malaria case incidence is still high, and there were major gaps between ITN ownership and compliance in malarious
malaria 3075 significantly decreased in Ethiopia and worldwide in the past decade [[1]]. Ethiopia’s fight against malaria started many years ago and transmission of this infectious disease significantly decreased since 1959
malaria 3206 and transmission of this infectious disease significantly decreased since 1959 [[1], [2]]. However, malaria still remains a major public health problem in Ethiopia [[1]]. Ethiopia has a population of nearly 100
malaria 3537 and P. vivax co-exist as major parasite species in Ethiopia [[1]]. This epidemiologic feature makes malaria control more complicated than in most African countries where P. vivax has low or nil endemicity.Malaria
malaria 3798 altitudes < 2000 m, although endemic regions > 2000 m have been reported [[3]–[5]]. The levels of malaria risk and transmission intensity, however, show marked seasonal, inter-annual and spatial variability,
malaria 4745 intervention strategies, the Federal Ministry of Health (FMoH) of Ethiopia has stratified the country’s malaria transmission burden using ‘woreda’ (district)-level transmission intensity according to annual parasite
malaria 5045 broad strata were identified by the mixed criteria of the FMoH and World Health Organization (WHO) — malaria free, low, moderate, and high transmission [[3], [9]].Plasmodium falciparum are endemic in many regions
malaria 5203 [9]].Plasmodium falciparum are endemic in many regions of the country [[3], [11]–[13]]. Plasmodium malaria e and P. ovale infection are uncommon and account for < 1% of confirmed malaria cases [[3], [11]].
malaria 5284 [11]–[13]]. Plasmodium malariae and P. ovale infection are uncommon and account for < 1% of confirmed malaria cases [[3], [11]]. Chloroquine (CQ) is currently the recommended first-line drug for treatment of vivax
malaria 5396 cases [[3], [11]]. Chloroquine (CQ) is currently the recommended first-line drug for treatment of vivax malaria [[11]]. In vivo monitoring of uncomplicated vivax malaria cases indicates that the CQ is generally efficacious;
malaria 5454 recommended first-line drug for treatment of vivax malaria [[11]]. In vivo monitoring of uncomplicated vivax malaria cases indicates that the CQ is generally efficacious; however, treatment failures have been reported
malaria 5593 generally efficacious; however, treatment failures have been reported [[14]–[17]]. The success of malaria control efforts has largely depended on financial support from donor funds [[1]].In the past decade
malaria 5768 donor funds [[1]].In the past decade Ethiopia has made significant strides in expanding coverage of key malaria interventions throughout the country. Indoor residual spraying (IRS) using dichlorodiphenyltrichloroethane
malaria 5928 residual spraying (IRS) using dichlorodiphenyltrichloroethane (DDT) was introduced in 1959 with the global malaria eradication campaign, and since then different chemical insecticides have been used for malaria control
malaria 6024 global malaria eradication campaign, and since then different chemical insecticides have been used for malaria control [[9], [18], [19]]. Insecticide-treated nets (ITN) were introduced in 1997 as an additional intervention
malaria 6200 introduced in 1997 as an additional intervention [[10]]. Chloroquine was the first line treatment of all malaria species in Ethiopia before 1998. It was replaced by sulfadoxine-pyrimethamine (SP) after 1998 for the
malaria 6499 [[20], [21]]. Parasites soon developed resistance to SP drugs [[22], [23]]. Planning for scaling-up malaria prevention and control interventions started in 2003 with the support from the Global Fund to Fight
malaria 6780 introduced artemisinin-based combination therapy (ACT) as the first-line drug for treatment of P. falciparum malaria as well as rapid diagnostic tests (RDT) to improve diagnosis and long-lasting insecticidal nets (LLINs)
malaria 7174 implementation of IRS [[3]].The aim of this study was to provide comprehensive evaluation of changes in national malaria control policy and progress made in malaria control interventions and malaria epidemiology in Ethiopia.
malaria 7218 provide comprehensive evaluation of changes in national malaria control policy and progress made in malaria control interventions and malaria epidemiology in Ethiopia. We discuss obstacles to malaria elimination
malaria 7252 of changes in national malaria control policy and progress made in malaria control interventions and malaria epidemiology in Ethiopia. We discuss obstacles to malaria elimination and review national malaria data
malaria 7310 made in malaria control interventions and malaria epidemiology in Ethiopia. We discuss obstacles to malaria elimination and review national malaria data from 2000 to 2016 and analyse these data in order to advance
malaria 7350 and malaria epidemiology in Ethiopia. We discuss obstacles to malaria elimination and review national malaria data from 2000 to 2016 and analyse these data in order to advance understanding of how changes in policy
malaria 7497 these data in order to advance understanding of how changes in policy have impacted temporal changes in malaria transmission in the country.Main textData collectionChanges in malaria control policy were reviewed
malaria 7568 impacted temporal changes in malaria transmission in the country.Main textData collectionChanges in malaria control policy were reviewed based on different sources including FMoH publications on malaria diagnosis,
malaria 7663 collectionChanges in malaria control policy were reviewed based on different sources including FMoH publications on malaria diagnosis, treatment and vector control guidelines, WHO guidelines, the President’s Malaria Initiative
malaria 7797 vector control guidelines, WHO guidelines, the President’s Malaria Initiative (PMI), and Ethiopian malaria control operational plans and reports [[10], [11], [18], [19], [24]–[30]]. National malaria data from
malaria 7891 Ethiopian malaria control operational plans and reports [[10], [11], [18], [19], [24]–[30]]. National malaria data from health facilities were collected through the Health Management Information System (HMIS).
malaria 8028 were collected through the Health Management Information System (HMIS). Total confirmed and clinical malaria cases, malaria cases by species, and reported deaths for all ages and age < 5 years between 2001
malaria 8043 through the Health Management Information System (HMIS). Total confirmed and clinical malaria cases, malaria cases by species, and reported deaths for all ages and age < 5 years between 2001 and 2016 were
malaria 8194 all ages and age < 5 years between 2001 and 2016 were reviewed. Incidence rate was expressed as malaria cases/1000 people/year and death rate as deaths/100000 people/year. Changes in number of health facilities,
malaria 8396 health facilities, annual number of tests (microscopic examination of blood smears and RDT) of suspected malaria cases, reports on new insecticide treated nets (ITN and LLIN), and IRS coverage from 2007 to 2016 were
malaria 8824 [[3]].Annual parasite incidence (API) according to district was analysed to characterize the district as malaria -free (API < 1.0), low (1.1–5.0), moderate (5.1–100), or high transmission (> 100) and to map
malaria 9373 Management Plan was used). Data from a total of 845 districts were analysed.Statistical analysisAPI and malaria death rates were calculated based on 2007 Ethiopian government census populations and 2013 projections
malaria 9599 national levels assuming constant population growth rate over the study period. Percent changes in malaria indicators from 2013 to 2016 were calculated according to the formula: (Value2013–Value2016)/Value2013 × 100.
malaria 9840 district level were generated using ArcGIS 10.0 (ESRI, Redlands, CA, USA). Numbers of districts with malaria -free, low, moderate and high API were calculated separately for 2013 and 2016. The total population
malaria 10305 tool VassarStats: Website for Statistical Computation (http://vassarstats.net/index.html).Evolving malaria control policyThe major policy changes in treatment were the replacement of CQ with SP for the first
malaria 10460 treatment were the replacement of CQ with SP for the first line treatment of uncomplicated P. falciparum malaria in 1998 and subsequent replacement with artemether-lumefantrine (AL), an ACT drug, in 2004 (Fig. 1).
malaria 10700 implemented in Ethiopia to improve diagnosis; however, the test-treat policy, i.e., administration of anti malaria l drugs was based on test results, was implemented in 2010 (Fig. 1). According to current national guidelines,
malaria 11135 intervention scheme in Ethiopia from 1990 to 2016CQ remains the first-line treatment of uncomplicated vivax malaria (Fig. 1) [[14]–[17]]. Anti-relapse therapy with primaquine for P. vivax malaria is currently recommended,
malaria 11217 uncomplicated vivax malaria (Fig. 1) [[14]–[17]]. Anti-relapse therapy with primaquine for P. vivax malaria is currently recommended, with supervised use, in malaria elimination-designated districts [[11]].LLIN
malaria 11275 Anti-relapse therapy with primaquine for P. vivax malaria is currently recommended, with supervised use, in malaria elimination-designated districts [[11]].LLIN were introduced into Ethiopia in 2004 as a method of malaria
malaria 11381 malaria elimination-designated districts [[11]].LLIN were introduced into Ethiopia in 2004 as a method of malaria prevention and control [[3]]. Major scale-up began in 2005 with country-wide distribution of LLINs free
malaria 11741 endemic areas below 2000 m altitude. Long lasting insecticidal nets have been provided free in all malaria endemic areas since 2011 [[27]–[29]].DDT and malathion were the main insecticides used for IRS before
malaria 12807 recommended as part of the vector control measures [[11], [32]]. Larval control is recommended for all malaria affected areas where breeding sites are permanent, identifiable, and few [[25], [30]]. Temephos (Abate®)
malaria 12977 identifiable, and few [[25], [30]]. Temephos (Abate®) is the recommended larvicide [[11]].Changes in clinical malaria incidenceThere has been an overall reduction in reported malaria incidence and deaths, increases LLIN
malaria 13042 larvicide [[11]].Changes in clinical malaria incidenceThere has been an overall reduction in reported malaria incidence and deaths, increases LLIN and IRS coverage and the number of health facilities from 2000
malaria 13351 from < 20% before 2008 to ~ 40% by 2012 and > 80% since 2013 (Fig. 2). There were three small malaria case increases in 2004, 2010, and 2012 (Fig. 2). Malaria incidence showed a general declining trend
malaria 13662 cases per 1000 people annually between 2001 and 2010 (before LLINs were made available free to all malaria affected people) to 29.0 cases per 1000 people between 2011 and 2016. This declining trend was more
malaria 14325 incidence of 0.6 cases per 100 000 people (Fig. 2, Table 1).Fig. 2National level annual total reported malaria cases, deaths due to malaria, and proportion of cases confirmed by microscopy or RDT from 2001 to 2016Table
malaria 14354 100 000 people (Fig. 2, Table 1).Fig. 2National level annual total reported malaria cases, deaths due to malaria , and proportion of cases confirmed by microscopy or RDT from 2001 to 2016Table 1Changes in malaria epidemiological
malaria 14453 malaria, and proportion of cases confirmed by microscopy or RDT from 2001 to 2016Table 1Changes in malaria epidemiological indicators in Ethiopia from 2013 to 2016Year20132016Change (%)Total reported cases3 316 0131 962 996−40.8 Confirmed2 645 4541 718 504−35.0 (%
malaria 15197 total)5.62.4−58.2 ≥ 5 years721498−30.9Malaria diagnosis and parasite speciesThe number of RDT and microscopy tested suspected malaria cases increased significantly from below one million before 2008 to 8.6 million in 2014 and an average
malaria 15500 increased from 79.8% in 2013 to 87.5% in 2016 (Table 1). Although there was year-to-year variation, malaria species changed little over time. Plasmodium falciparum accounted for ~ 60% of cases (range 55–69%)
malaria 15867 species composition from 2001 to 2016. Pf: Plasmodium falciparum; Pv: Plasmodium vivaxIntensification of malaria interventions and increase in number of health facilitiesFMoH has distributed 18.2 million ITN/LLINs
malaria 16559 facilities nationally has steadily increased from 3612 in 2000 to 6604 in 2005, just before the scale-up of malaria interventions. The total number of health facilities in 2016 was 20 283 (Fig. 4c).Fig. 4National level:
malaria 17110 insecticidal net; and IRS: indoor residual sprayingChanges in spatial transmission patternsOverall malaria -related hospital admissions showed no significant change between 2013 and 2016 (Table 1). However, malaria
malaria 17217 malaria-related hospital admissions showed no significant change between 2013 and 2016 (Table 1). However, malaria deaths decreased significantly from 2013 to 2016. Reported malaria cases in children < 5 years decreased
malaria 17284 2013 and 2016 (Table 1). However, malaria deaths decreased significantly from 2013 to 2016. Reported malaria cases in children < 5 years decreased by 59.3% between 2013 and 2016, from a total of 785 895 to
malaria 18595 indicating increase). API: annual parasite incidence per 1000 populationTable 2Changes in distribution of malaria transmission intensity and affected populations at district level in Ethiopia from 2013 to 2016APINumber
malaria 19207 in percentages from 2013 to 2016, numbers in brackets indicating negativeThe reduction in clinical malaria was not uniform across the country (Fig. 5c). The majority of districts experienced reductions in incidence
malaria 19619 Awi Zone of Amhara Region. By contrast, there were 59 districts with noticeable increases in clinical malaria incidence (API > 5) from 2013 to 2016, and two districts with increases in API > 100, i.e.,
malaria 20021 interventionsEthiopia is one of the few countries in sub-Sahara Africa with a policy to provide the main malaria prevention and control services free of charge, including malaria diagnosis and treatment, mosquito
malaria 20087 with a policy to provide the main malaria prevention and control services free of charge, including malaria diagnosis and treatment, mosquito nets and IRS [[3], [11]]. This policy has ensured accessibility of
malaria 20208 treatment, mosquito nets and IRS [[3], [11]]. This policy has ensured accessibility of the poor to malaria interventions and, hence, protection from malaria to increase household economic productivity. We emphasize
malaria 20258 This policy has ensured accessibility of the poor to malaria interventions and, hence, protection from malaria to increase household economic productivity. We emphasize that, in Ethiopia, the success of these policies
malaria 20450 success of these policies largely depended on donor funds [[1], [25]–[30]]. The overall reduction of malaria burden is evident since 2013, reflected in the shrinkage of the malaria map between 2013 and 2016, particularly
malaria 20522 [25]–[30]]. The overall reduction of malaria burden is evident since 2013, reflected in the shrinkage of the malaria map between 2013 and 2016, particularly in the central highlands of Ethiopia where no high transmission
malaria 20706 where no high transmission was observed in 2016. Anti-relapse therapy with primaquine for P. vivax malaria is not currently recommended in malaria-endemic areas [[1]]. However, the national malaria case management
malaria 20746 in 2016. Anti-relapse therapy with primaquine for P. vivax malaria is not currently recommended in malaria -endemic areas [[1]]. However, the national malaria case management guidelines outline the specific recommendations,
malaria 20797 P. vivax malaria is not currently recommended in malaria-endemic areas [[1]]. However, the national malaria case management guidelines outline the specific recommendations, including the use of a full 14-day
malaria 20958 recommendations, including the use of a full 14-day course of primaquine for radical cure of P. vivax at malaria elimination-designated districts and single dose primaquine for gametocytocidal activity against P.
malaria 21234 intervention, the case burden is expected to decrease in the near future.There was clear decrease in malaria incidence rate and malaria death rate in Ethiopia from 2001 to 2016; however, malaria case number and
malaria 21261 burden is expected to decrease in the near future.There was clear decrease in malaria incidence rate and malaria death rate in Ethiopia from 2001 to 2016; however, malaria case number and incidence remained high—19.8
malaria 21320 clear decrease in malaria incidence rate and malaria death rate in Ethiopia from 2001 to 2016; however, malaria case number and incidence remained high—19.8 cases per 1000 people reported in 2016 exceed the WHO
malaria 21851 Therefore, there is ample opportunity to increase LLIN and IRS coverage which would be expected to decrease malaria transmission further. There is a clear need to improve the mechanism of LLIN distribution so that all
malaria 22102 covered.New risk factorsAlthough the FMoH of Ethiopia has classified areas at altitudes > 2000 m as malaria -free zones [[10]], they are not entirely malaria free at the district level. In fact, many of these
malaria 22151 Ethiopia has classified areas at altitudes > 2000 m as malaria-free zones [[10]], they are not entirely malaria free at the district level. In fact, many of these districts have moderate APIs according to this study.
malaria 22443 due to local environmental suitability [[10], [34]]. For example, construction of dams might increase malaria transmission in the valleys of highland areas where overall malaria transmission was very low [[35]].
malaria 22511 construction of dams might increase malaria transmission in the valleys of highland areas where overall malaria transmission was very low [[35]]. These dams create transmission hot spots along valleys where irrigation
malaria 22912 investigation of this issue is warranted.Confirmed cases are still highThere have been significant advances in malaria diagnosis and prevention in Ethiopia since the beginning of scale up in 2004 [[8], [28], [38], [39]].
malaria 23450 1 718 504 confirmed cases by either method. Meanwhile, the FMoH reported the total number of clinical malaria cases to be 1 962 996, and the proportion of clinically diagnosed cases based on symptoms alone
malaria 23638 based on symptoms alone reduced to 12.5% in 2016. This was a result of successful implementation of the malaria test-treat policy.Challenges for further reducing malaria transmissionMalaria transmission is very heterogeneous
malaria 23696 result of successful implementation of the malaria test-treat policy.Challenges for further reducing malaria transmissionMalaria transmission is very heterogeneous across Ethiopia. The malaria burden is still
malaria 23780 further reducing malaria transmissionMalaria transmission is very heterogeneous across Ethiopia. The malaria burden is still high in western Ethiopia near the borders of Sudan and South Sudan. This suggests that
malaria 23983 suggests that these high burden areas need to be prioritized to sustain the gains made so far and achieve malaria elimination. In central Ethiopia, particularly the central highlands, malaria transmission has been
malaria 24061 made so far and achieve malaria elimination. In central Ethiopia, particularly the central highlands, malaria transmission has been significantly reduced, and many of these areas have reached pre-elimination levels
malaria 24269 levels of transmission. These results are similar to those of a previous study showing a reduction in malaria incidence in central Ethiopia after ITN distribution [[40]–[42]]. Nevertheless, malaria epidemiology
malaria 24359 reduction in malaria incidence in central Ethiopia after ITN distribution [[40]–[42]]. Nevertheless, malaria epidemiology in western Ethiopia has clearly been under-studied [[10], [38], [39]]. In addition, dealing
malaria 24644 for the central highlands. Finally, in the Somalia Region of eastern Ethiopia bordering Somalia where malaria reporting is less accurate due to inadequate capacity, better surveillance systems are desperately needed
malaria 24772 accurate due to inadequate capacity, better surveillance systems are desperately needed in the era of malaria elimination [[10]].ConclusionsMalaria morbidity and mortality have significantly declined in Ethiopia
malaria 25291 area of western Ethiopia to sustain achievements made to date and hasten the endeavour of achieving malaria elimination.Additional fileAdditional file 1:Multilingual abstracts in the five official working languages

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