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Malaria Prevention and Control in Ethiopia. Dr Afework Hailemariam, National Malaria Control Program, Ethiopia. Country Profile –Malaria Burden. 75% of the land malarious (altitude < 2000 m), >50 million(68%) of the population at risk, Malaria is the first cause of illness & death (2003/04)

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Malaria prevention and control in ethiopia l.jpg

Malaria Prevention and Control in Ethiopia

Dr Afework Hailemariam,

National Malaria Control Program, Ethiopia


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Country Profile –Malaria Burden

  • 75% of the land malarious (altitude < 2000 m),

  • >50 million(68%) of the population at risk,

  • Malaria is the first cause of illness & death (2003/04)

    • OPD 15.5%: 1st

    • Admissions 20.4%: 1st

    • Hospital Deaths 27.0%: 1st

  • Transmission season- Sept.- Dec., April- May, (seasonal & unstable)

  • Coincide with major harvesting season; aggravate economic loss,

  • Major epidemics occur every 5 - 8 years, focal epidemics are common,


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Impact of malaria control interventions:

Trends in Malaria Cases, Admissions and Deaths


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Yearly Confirmed Malaria Cases, ETHIOPIA (1990 – 2006)REMARK: 2005 – 2006 data from Benishangul Gumuz & Dire Dawa not Included

Source: health and health related indicators and data collected from Regional Health Bureaus, FMOH


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Yearly Malaria Out-Patients, ETHIOPIA (July 2000 – June 2006)REMARK: no data from Benishangul Gumuz and Dire Dawa for the year 2005 - 2006

Source: data collected from Regional Health Bureaus, FMOH


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Yearly Total Examined Cases and Malaria Positives, ETHIOPIA(July 2000 – June 2006)REMARK: no data from Benishangul Gumuz &Dire Dawa for the year 2005 - 2006

Source: data collected from Regional Health Bureaus, FMOH


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Yearly Malaria Admissions, ETHIOPIA (July 2000 – June 2006)REMARK: no data from Benishangul Gumuz and Dire Dawa for the year 2005 - 2006

Source: data collected from Regional Health Bureaus, FMOH


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Yearly Total Malaria Deaths, ETHIOPIA (1990 – 2006)REMARK: no data from Addis Ababa, Benishangul Gumuz &Dire Dawa for the year 2005 - 2006

Source: data collected from Regional Health Bureaus, FMOH


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Yearly Based Malaria Epidemics Recorded, ETHIOPIA (July 2000 – June 2006)REMARK: no data from Benishangul Gumuz &Dire Dawa for the year 2005 - 2006

Source: data collected from Regional Health Bureaus, FMOH


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Yearly Malaria Epidemics Recorded, ETHIOPIA(July 2000 – June 2006)REMARK: no data incorporated from Benishangul Gumuz and Dire Dawa Regional States for the year 2005 - 2006

Source: data collected from Regional Health Bureaus, FMOH


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Strategic Approaches

1) MAIN TECHNICAL ELEMENTS OF STRATEGIC APPROCHES:

  • Early diagnosis and effective treatment

  • Vector control

    • Insecticide treated materials

    • Residual house spray

    • Other vector control methods; Environmental Mx, Larviciding etc

  • Epidemic prevention and control

    2) SUPPORTING STRATEGIES:

    • Human resource development

    • Operational research

    • Information, education and communication

    • Program monitoring and evaluation


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    General Objective

    To reduce the overall burden of malaria (mortality and morbidity) by 50% by 2010.


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    Specific Objectives

    • Achieve 100% access to effective and affordable treatment for malaria by the end of 2008

    • Achieve 100% coverage of all households in ITNs targeted districts with at least two ITNs per household by August 2007,


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    Specific Objectives contd….

    • Achieve 60% coverage of villages targeted for Indoor Residual Spraying (IRS) the end of 2010 as compared to the 20-30% coverage in 2005,

    • Early detect and contain 80% of the malaria epidemics within two weeks from onset by 2010 as compared to 31% in 2005,







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    Major Achievements: Vector Control/ITNs control

    Vector Control: LLINs

    • 15.5 million LLINs have been Distributed to users

    • 5,108,168 nets have been procured and is on pipeline

    • 700,000 gap is secured or now under negotiation with partners (GF)

    • 88 % coverage at 2 ITNs per household


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    ITN scaling-up in Ethiopia control

    • Target 100% net coverage, 2007

    • 2 ITNs per malaria affected household

    • Prioritize children & pregnant women

    Estimated total number of ITNs in Ethiopia

    97% LLINs

    Arrival of LLINs

    Net with 6-month treatments



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    Yearly Unit Structures Targeted for Indoor Residual Spraying, ETHIOPIA (July 2000 – June 2006)REMARK: no data incorporated from Amahara, Benishangul Gumuz, and Dire Dawa Regional States for the year 2005 - 2006

    Source: data collected from Regional Health Bureaus, FMOH


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    Indicative Budget Requirement (2006 – 2010) Spraying, ETHIOPIA (July 2000 – June 2006)


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    GF ATM Spraying, ETHIOPIA (July 2000 – June 2006)

    UNICEF

    WHO

    CIDA/CANADA

    The Carter Center

    USAID/PMI

    PSI

    PBS/The World Bank

    Japan/JICA

    DFID

    Other partners

    Major sources of fund in malaria prevention and control activities


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    Data required for new malaria Spraying, ETHIOPIA (July 2000 – June 2006)intervention introduction decisions

    • Efficacy and Effectiveness

    • Length of protection

    • Cost effectiveness compared to other interventions

    • Safety in different risk groups - <5s; pregnant women; breastfeeding;

    • High Reduction of occurrence of sever malaria

    • Potential for wide-spread use – all levels of health care system & community level,

    • Consumer acceptability

    • Formulation;

    • dosage regimen; taste,

    • Potential to delay resistance


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    Example of decision-making Spraying, ETHIOPIA (July 2000 – June 2006)

    • Policy change to ACTs is a good example

      • Efficacy study,

      • Validation of findings

      • Dissemination workshop

      • Recommendation

      • Guideline revision

      • Training of health workers

      • Resource mobilization and procurement

      • Implementation of the new policy


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    Example of decision-making Anti-Malaria Drug Resistance in Ethiopia

    • Results from Isolated studies showed different levels of resistance to SP,

      • Less than 5% in Humera (1994) & Alamata (1998)

      • Treatment failure rate of 18% in Zuwai in 1998 Institute of Pathobiology,

      • Treatment failure rate of 30% in Zuwai in 2000 Institute of Pathobiology,

    • Not representative & lack of standardized protocol

    • Nationwide representative study not conducted in the period 1999 – 2002,


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    Nationwide Assessment on the Efficacy of Sulfadoxine-Pyrimethamine

    A nationwide in-vivo Therapeutic Efficacy Study on

    Sulphadoxine-Pyrimethamine For the Treatment of Uncomplicated

    falciparum Malaria conducted in 11/14 sites,

    October – December 2003


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    Anti-Malaria Drug Resistance Monitoring sites Sulfadoxine-Pyrimethamine

    SP

    AL

    ND


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    Mean treatment failure Sulfadoxine-Pyrimethamine

    35.9% (95%CI: 21.7 – 47.8)

    Sulfadoxine-Pyrimethamine Efficacy Study Findings & Treatment Policy Change

    80% of the

    sites with

    TF rate of > 25%


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    Treatment Failure Cut-offs & Recommended Actions Sulfadoxine-Pyrimethamine

    >25% Change Period (reach consensus for change with in the shortest time possible)

    6-15%: Alert Period (mechanism for the process of change)

    16-24%:Action Period (activities to initiate change)

    <5%: Grace Period (active monitoring)

    5

    15

    25


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    Is There a Need to Change? Sulfadoxine-Pyrimethamine

    • YES!

      • Preliminary findings of the nationwide therapeutic efficacy study results on sulfadoxine-pyrimethamine show treatment failure rates that warrant for change,

      • The need to use safe and effective anti-malaria drugs during malaria epidemics

      • Which drug (s)?


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    National Workshop on Anti-Malarial Treatment Policy in Ethiopia – May 2004

    • All stakeholders invited (about 90 participants)

    • Consensus reached on the Need to revise the diagnosis & treatment policy,

    • Rational to switch to more effective Artemisinine Based Combination Therapy (ACTs) than mono-therapy discussed,

    • Anti-malarial treatment options reviewed

    • Treatment of uncomplicated falciparum malaria

      • Artemether-Lumefantrine (highly recommended)

      • Artesunate + Amodiaquine (not recommended)

      • Artesunate + Sulfadoxine-Pyrimethamine (NR)

      • Artesunate + Mefloquine (needs investigation)

      • Non ACT option: SP + Amodiaquine (NR)


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    Minimal criteria for selection of Anti-malarial drugs Ethiopia – May 2004

    • Therapeutic efficacy – Clinical and parasitological cure

    • Safety in different risk groups - <5s; pregnant women; breastfeeding;

    • Potential for wide-spread use – all levels of health care system & community level,

    • Consumer acceptability- formulation; dosage regimen; taste,

    • Cost effectiveness

    • Potential to delay resistance


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    Recommended Options for Ethiopia Ethiopia – May 2004

    • Treatment of uncomplicated falciparum malaria

      • Artemether-Lumefantrine (highly recommended)

      • Artesunate + Amodiaquine (unlikely due to failure of AQ)

      • Artesunate + Sulfadoxine-Pyrimethamine (unlikely due to failure of SP)

      • Artesunate + Mefloquine (needs investigation)

      • Non ACT option: SP + Amodiaquine (unlikely due failure of both)

    • Treatment of vivax malaria (Chloroquine, Primaquine (radical cure)

    • Treatment of Sever & complicated malaria – Quinine

    • Chemoprophylaxis (Daily Proguanil + weekly chloqroquine)

    • Other issues to be considered

      • Need to identify safe drugs for the treatment of malaria during pregnancy,

      • Treatment of sever and complicated malaria in peripheral health facilities during malaria epidemics,

      • Chemo prophylactic drug for travellers (with easy dose regimen).


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    1. Artemether - Lumefantrine Ethiopia – May 2004

    • AM-LUM is highly recommended:

      • Very past parasite elimination

      • Prompt reduction in fever

      • Effective gametocyte clearance

      • Effective in multi-drug resistant areas

      • Does not show any evidence of organ or system specific toxicity

      • Fixed dose combination treatment


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    Efficacy Study Results of Artemether-Lumefantrine on Ethiopia – May 2004P. falciparum Infections (Sep. – Dec. 2004)


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    1. Artemether – Lumefantrine… Ethiopia – May 2004

    Course-of-therapy blister packs with simplified instructions for illiterate patients

    • 4 different packs:

    • 10-14 kg (1-2 yrs)

    • 15-24 kg (3-7 yrs)

    • 25-34 kg (8-10 ys)

    • 35+ kg (11+ ys)


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    Together We Can Beat Malaria! Ethiopia – May 2004

    Thank you


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