Malaria Prevention and Control Efforts in Ethiopia

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Malaria Prevention and Control Efforts in
Ethiopia

• 4th CORPORATE AFRICAPARTNERSHIPS FOR PREVENTION
  AND CAREAFRICA HEALTH CONFERENCE
  EXHIBITIONBusinesses Challenge Diseases in the
  21st Century7-9 February, 2011

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Outline

• Background
• Malaria Epidemiology
• Goals
• Government Policy towards Malaria Control
• Malaria Control strategies
• Partnership
• Achievements
• Malaria Burden
• Challenges
• Future Directions

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Background

• Malaria is a killer parasitic disease
• It causes more than 800,000 deaths and estimated
  2.7 million cases annually
• It threatens more than 40 of the world's
  population widespread in 100 countries and
  territories worldwide, largely in the less
  developed tropical areas of Africa, Asia, and
  Latin America
• In Africa, malaria is the leading cause of
  morbidity and mortality
• 88 of deaths and 83 of cases occur in Africa
  south of the Sahara

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Malaria Epidemiology in Ethiopia

• 75 of the land (areas below 2000 m above sea
  level) is malarious
• Fertile low land areas
• Suitable for agriculture
• gt54 million (68) population live in these areas
  and are at risk of malaria
• Transmission is unstable and seasonal
• September to December and April to May
• Coincide with major planting and harvesting
  season for farmers - aggravate economic loss

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Malaria Epidemiology in Ethiopia (2)
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Epidemiology(3)

• Major epidemics occur every 5 - 8 years, but
  focal epidemics was occurring every year until
  2008,
• Two parasite species
• Plasmodium falciparum (60)
• P. vivax (40)
• Main malaria vector
• Anopheles arabiansis
• (A. pharoensis, A. nili,
• and A. funesteus are secondary vectors)

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The goal of malaria prevention and control in
Ethiopia

• Ultimate goal is to reduce the burden of malaria
  to the level it is no more a public health
  problem
• To contribute to MDG 6 target 8 by reducing the
  overall burden of malaria by 50 by the year 2010
  and another 50 by 2015.
• To contribute to the reduction of child mortality
  (MDG 4) and improvement of maternal health (MDG
  5)

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Gov. policy towards malaria control

• Priority to communicable diseases
• Free diagnosis (especially at lower health
  facilities level)
• Free anti-malarial drugs
• Free distribution of ITNs to all
• Free indoor residual spraying of houses

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Malaria Control Strategies in Ethiopia

• 1) Main strategies
• Diagnosis and Case Management, including active
  case detection
• Vector control
• Insecticide treated nets
• Indoor Residual Spray
• Active Surveillance and Epidemic prevention and
  control
• 2) Cross cutting Strategies
• Human resource development
• Operational research
• Information, education and communication
• Program monitoring and evaluation

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Major Activities

• Training of Health Workers at different levels
• Procurement and distribution of Malaria
  commodities and logistics
• Health System Strengthening
• Strengthening HMIS
• IEC/BCC
• Supervision/ME
• Operational Research

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Partnership in the Fight against Malaria

• Major sources of fund in malaria prevention and
  control activities
• GFATM
• UNICEF
• WHO
• USAID/PMI
• CIDA/CANADA
• PBS/WB
• UNITAID
• Other partners

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Achievements Dx and Tx

• Guideline revised in 2004
• Diagnosis
• Clinical, Rapid Diagnostic Tests and Microscopy
• The guideline is on Revision
• Multispecies RDT at HP and Microscopy at HC
  Hospital
• Treatment
• 1st line - Artemether-Lumefantrine (Coartem) for
  P.falciparum and CQ for P.vivax
• Quinine for pregnant women children lt5kg
• 2nd line treatment quinine tablets
• Severe malaria quinine injection
• Prereferral Rx- Artesunate Suppository

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Major Achievements Dx and Tx

• Target Universal coverage of fever treatment
  within 24 hours onset of fever in 2009
• RDT procurement and distribution
• Procurement and distribution of Coartem

Coartem doses in Millions
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Achievements Dx and Tx

• Strength
• Accelerated expansion of primary health service
  coverage - universal health service coverage by
  2010
• Health extension program
• Better financial input GFATM

• More than 32,000 HEWs already deployed (2 per
  Kebele of 5000 inhabitants)
• Training of health officers

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Achievements LLINs

• Target to cover all households in malarious
  areas with at lease 2 nets per household (20
  million nets) in 2008 and to protect more than 50
  million people.
• Since 2005, more than 20.4 million LLINs have
  been distributed to beneficiaries
• 100 coverage of all households in malaria risk
  areas with an average of 2 nets per household
• Protected more than 50 million people from malaria

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Status of LLINs Distribution

• LLINs
• Total distributed for replacement are 18.8
  million
• 3.4 million distributed in 2008/9
• 11.2 Million LLINs are procured through GFATM
• 1.6 Million LLINs through PMI
• 1.62 Million World Bank
• 1.00 million MDG fund
• A total of around 17 Million LLINs are procured
  and are being Distributed to Woredas through PFSA
  in 2010.
• Can protect more than 45 million people from
  malaria.
• 1.8 million LLINs are on procurement through PMI
• Recently 9.9 Million USD has been secured from
  WB/PBS to fill the gap of 2 million LLINs to
  universal coverage.

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Status of ITN Distribution
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Net ownership and percentage of HH that received
IRS - MIS 2007
MIS 2007 - national
MIS 2007 - lt2000m
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Current Intervention Coverage Summary MIS 2007
Indicators DHS 2005 DHS 2005 MIS 2007 MIS 2007
Indicators National Malarious National Malarious
of HH with at least one net (any net) 5.7 10.7 55.7 69
of HH with at least one ITN 3.4 6.4 53.3 66
use of nets (any nets) by children under five 2.3 4.3 34.7 44
use of ITNs by children under five 1.5 2.8 33.1 42
use of nets (any net) by pregnant women 1.6 2.5 36.7 44
use of ITNs by pregnant women 1.1 1.6 35.2 43
of children who had a fever in the two weeks preceding the survey 18.7 22.3 24
of children with a fever who took an anti-malarial (within 24 hrs) 3 (0.7) 9.5 (3.9) 12 (5)
malarious areas defined as areas lt2000 meters
elevation 2005 DHS did not include this
measure. among those in HH with a net, net-use
rates for children or pregnant women were 60 and
66 respectively
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Achievement IRS

• Target to cover at least 90 of all sprayable
  localities by 2013
• Indoor residual spraying has been implemented for
  more than 4 decades.
• Cost of Insecticides is covered by RHB GF
  partners.

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Achievement IRS

• In recent years gt30 of sprayable localities were
  sprayed,
• The coverage was further increased (55) last
  year.
• Nationwide insecticide susceptibility test has
  been done.
• The insecticide to be used is changed to
  Deltamethrin.

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Achievement IRS

• 600,000 kg of Deltamethrin 2.5WP and 60,000kg of
  Deltamethrin 25 WDG
• This can spray 12 million Unit Structures.
• The achievement for the last major transmission
  season was 55(6,305,251 housing units)(2009
  Regional Reports)
• 8,300 spray pumps (7,100 Spray pumps has been
  procured from GFATM through UNICEF and 1,200
  spray pumps by PMI).
• Operational Cost- disbursed to Regions.
• Revision of vector control guideline

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Trends in burden of Malaria

• In general the overall burden of malaria
  morbidity and mortality decreased significantly
  over the last three years
• Number of malaria epidemic affected villages
  /epidemic calls have also reduced
• This significant impact is documented by a health
  facility based survey by WHO/HQ GFATM.
• Scaling-up of key malaria interventions reduced
  the malaria-related burden to health facilities
  by about 50 within 5 years.. (Health Facility
  Survey, 2009)

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Monthly mean difference of inpatient malaria
cases and deaths for the pre-intervention
(2002-2005) and post-intervention periods
(2006-2009), excluding November and December of
each year. 27 HFs, 2002--2009.
25
 Malaria inpatient cases and deaths by month, 27
HF, 2002--2009
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HFS 2009 Results

• Malaria in-patient cases increased in 2003 and
  were fairly stable between 2004 and 2005 but
  declined gradually thereafter, both among
  children under-5 and in the older age group.
• Among children under-5, the percentage of malaria
  cases decreased from 20 in 2002 to 12 in 2008.

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Cond

• Among under-fives, among all-cause deaths, the
  proportion due to malaria fell from 17 in 2002
  to 7 in 2008
• Similarly, in the older age group the proportion
  of malaria deaths decreased from 16 in 2002 to
  6 in 2008).

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Cond

• Malaria out-patient cases peaked to 23,033 in
  2002, among children under-5 and declined to
  12,267 in 2008, where as in 5 and above it peaked
  to 95,066 in 2003 and declined to 44,914
• The decline was more marked by paralleled
  decrease in the slide positivity rate. Numbers of
  slides examined remained constant while the slide
  positivity rate showed a declined in all ages.

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Malaria Epidemics Recorded, Ethiopia (July 2000
June 2008)
Source data collected from Regional Health
Bureaus, FMOH
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Summary of Achievements

• Scaling-up of key malaria interventions reduced
  the malaria-related burden to health facilities
  by about 50 within 5 years.. (Health Facility
  Survey, 2009)
• Universal Access to Diagnostics and Treatment
• Universal Coverage of LLINs by the end of 2011.
• Scale up of IRS to 55 in 2009.
• Scale up of IEC/BCC activities to increase uptake
  of malaria interventions.
• Strengthened human resource capacity- training
  of 160 programme managers in 2010.
• Strengthened OR and ME system
• Establishment of PHEM to strengthen the
  surveillance system
• Strengthened Partnership

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Malaria Burden in Ethiopia
Table 1. Weighted mean of percentage decline of
malaria admission, death, outpatient cases key
malaria indicators in children under 5 year and
gt5 years, Ethiopia 2001-2007.
Age admission Death OPD malaria OPD malaria -confirmed Slide positivity rate
gt 5 years -55 -34 -48 -70 ---
lt 5 years -52 -56 -47 -61 ---
All ages -54 -55 -48 -67 -38
Compared Mean 2001 2004 as baseline Vs 2007
data Source Global Malaria Program Department,
WHO, Geneva
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Challenges

• Insecticide resistance
• Climatic anomalies
• Compliance to drug in use
• Delay in replacement of the old nets
• Misuse of the existing nets by the households
• Delay of reports from regions

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Future Direction
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Vision and Goal

• Vision To see malaria free Ethiopia
• Goal
• By 2015, achieve malaria elimination within
  specific geographical areas with historically low
  malaria transmission
• By 2015, achieve near zero malaria death in the
  remaining malarious areas of the country

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Goals, objectives and strategies
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2009 and beyond (1)

• Ensure 100 coverage of LLINs by 2009
• Fill the gap of LLINs ensure replacement
• Sustain 100 coverage throughout
• Increase the utilization rate
• Ensure continuous supply of
• Anti-malaria drugs
• RDTs (multispecies)
• Other supplies, e.g. lab reagents
• Scale up IRS
• Where to focus determined by resource
  availability

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2009 and beyond (2)

• Active surveillance throughout the country
• HEWs
• Weekly report to the national level
• Define thresholds at Health Post level
• Start implementation of the elimination strategy
• Preparation of all the necessary documents
• Community empowerment and mobilization

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Thank You !!