Ethiopia

In Ethiopia, malaria is highly seasonal, and unstable with epidemic-prone transmission patterns in many parts of the country.[1] High malaria risk areas are mainly located in the western lowland areas of the country. Generally, around 52% of the country’s population is at risk of the disease. Due to the unstable and seasonal pattern of malaria transmission, the protective immunity of the population is generally low, and all age groups are at risk of infection and disease.[2]

Plasmodium falciparum (~65 percent) and Plasmodium vivax (~35 percent) are the major malaria parasites. An. arabiensis is the primary malaria vector in Ethiopia, with An. funestus, An. pharoensis, and An. nili as secondary vectors. Recent evidence suggests that An. coustani may also play a role as a vector. .[1]

In Ethiopia, malaria is highly seasonal and unstable with epidemic-prone transmission patterns in many parts of the country. Peak malaria transmission occurs between September and December, after the main rainy season from June to August. In addition, some areas experience a second minor malaria transmission period from April to June, following a short rainy season from February to March. Because of the unstable nature of malaria in Ethiopia, adults and children are equally at risk for malaria infection and disease. As peak malaria transmission often coincides with the planting and harvesting season, the majority of malaria burden is among older children and working adults in rural agricultural areas, thus there is a resultant heavy economic burden in Ethiopia.[1]

Overall, Ethiopia is among the fifteen countries with the highest rates of malaria cases and deaths. In 2020, it accounted for 1.7% of global malaria cases and deaths, 1.5% of malaria deaths, and 7% of malaria cases in East and Southern Africa. [3]

Between 2020 and 2021, the estimated number of malaria cases decreased by 12.8%, from 53 to 46 per 1000 of the population at risk, and estimated malaria deaths decreased 16.9%, from 0.12 to 0.10 per 1000 of the population at risk.[3]

The Ethiopia national malaria elimination strategic plan proposes to eliminate malaria in districts with an annual parasite index less than 10 by 2025 and the total elimination of malaria from Ethiopia by 2030. Ethiopia has declared malaria elimination efforts in 236 selected districts, encompassing six different regions, starting in 2017.[1]

The Ethiopia Malaria Elimination Strategic Plan (2021–2025) doesn’t recommend IPTp, IPTi, or SMC. The low and very low malaria transmission areas are targeted for malaria elimination and the interventions include case investigation and targeted mass drug administration.

The NMSP aims to achieve adoption of appropriate behavior and practices toward antimalarial interventions by 85 percent of households living in malaria-endemic areas by 2025. To achieve this objective, the NMEP utilizes health extension workers (HEWs), health development armies, and model family households to deliver SBC interventions. About 52 percent of the people live in areas at risk of malaria. The highest malaria burden regions are usually areas of intense malaria transmission with altitudes below 1,000 meters.

DHIS 2 has also been rolled-out and scaled-up nationwide. Current national malaria priorities include improving data quality through routine data quality audits (RDQAs) and data review meetings at the districts, improving DHIS2 timeliness and completeness, and creating a data use “culture,” especially in elimination districts to monitor malaria hot spots and respond promptly. There are major challenges regarding data quality and access in Ethiopia.

 

Case Management 

The Federal Ministry of Health states that artemether-lumefantrine (AL) with single low-dose primaquine should be used to treat P. falciparum infections. Oral quinine remains the treatment of choice for uncomplicated P. falciparum for pregnant women during the first trimester of pregnancy, and as second-line for treatment failures.[1]

Rectal artesunate should be available at rural health posts for pre-referral intervention for children under six years of age, and parenteral artesunate or intramuscular artemether (alternate) should be available at health centres and hospitals for the treatment of severe malaria.[1]

Malaria diagnosis and treatment, together with the treatment of pneumonia, diarrhoea and other diseases, are given at the Health Posts (HPs) by Health Extension Workers (HEWs) through Integrated Community Case Management (iCCM). In 2019/20 almost 60% of malaria cases were managed at this grass root level.[2]

Insecticide-Treated Nets (ITNs) 

According to the 2015 MIS, 64 percent of all households owned at least one ITN in malarious areas (areas <2,000m above sea level). Since 2015, Ethiopia has held four subnational campaigns, distributing more than 35 million nets.[1]

According to an NMEP report regarding survey on ownership and use of long-lasting insecticidal nets and malaria treatment seeking behaviour in Ethiopia (September 2020), 67 percent of households own at least one ITN, and on average households own 1.8 ITNs, an increase from 64 percent and 1.3 net per household in 2015 MIS (Figure A-10). It was found that 62 percent of the households have received ITNs in the past three years. Ownership of at least one ITNs was higher in rural areas (70 percent) than urban areas (55.4 percent) and in the high malaria burden regions, Gambela was the highest (86 percent) followed by Somali (83 percent) in ITNs ownership.[1] According to a National Malaria Elimination Program survey report, there is some improvement in ITN use among children under five years of age and pregnant women in 2020. Accordingly, 62% of pregnant women and 52%of children under five years of age were found sleeping under ITNs, increases from 35% and 38%, respectively, in 2015.[1]

Challenges 

Ethiopia is also challenged with an emerging parasite deletion in a gene that encodes for a histidine-rich protein 2 (HRP-2) which is the primary target for rapid diagnostic tests (RDTs). This deletion combined with deletion of HRP-3, which can cross-react, makes the parasite unable to be detected by HRP-2-based RDTs.

The other major challenge facing Ethiopia is the return of seasonal migrant workers harboring malaria infection to low or eliminated malaria areas. This poses a challenge to achieving and maintaining malaria elimination in Ethiopia.

The conflict situation in the northern part of Ethiopia, as well as continuing armed conflicts in other regions (eg. Oromia, SNNP, and Benishangul-Gumuz) have increased humanitarian needs and caused a discontinuation of essential health services.

The NMSP proposes to reduce malaria morbidity and mortality by 50 percent from the 2020 baseline and eliminate malaria in districts with an annual parasite index (API) less than 10 by 2025. The NMSP also proposes achieving malaria elimination by 2030.

Severe malaria policy and practice 

National treatment guidelines

Recommendation	Treatment
Strong	Injectable or intramuscular artesunate
Alternative	Injectable artemether

*Injectable artesunate and artemether is not recommended for use during the first trimester of pregnancy. 

Pre-referral recommendation	Treatment
Strong	ARC for children under five years of age