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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

Malaria Prevention and Control in Ethiopia

Dr Afework Hailemariam,

National Malaria Control Program, Ethiopia

country profile malaria burden
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,
impact of malaria control interventions trends in malaria cases admissions and deaths
Impact of malaria control interventions:

Trends in Malaria Cases, Admissions and Deaths

slide5
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

slide6
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

slide7
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

slide8
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

slide9
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

slide10
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

slide11
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

strategic approaches
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
general objective

General Objective

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

specific objectives
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,
specific objectives contd
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,
major achievements vector control itns
Major Achievements: Vector Control/ITNs

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
slide22
ITN scaling-up in Ethiopia
  • 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

slide24
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

major sources of fund in malaria prevention and control activities
GF ATM

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
data required for new malaria intervention introduction decisions
Data required for new malaria 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
example of decision making
Example of decision-making
  • 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
slide30
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,
slide31
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

sulfadoxine pyrimethamine efficacy study findings treatment policy change
Mean treatment failure

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%

slide34
Treatment Failure Cut-offs & Recommended Actions

>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

is there a need to change
Is There a Need to Change?
  • 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)?
slide36
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)
minimal criteria for selection of anti malarial drugs
Minimal criteria for selection of Anti-malarial drugs
  • 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
recommended options for ethiopia
Recommended Options for Ethiopia
  • 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).
1 artemether lumefantrine
1. Artemether - Lumefantrine
  • 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
efficacy study results of artemether lumefantrine on p falciparum infections sep dec 2004
Efficacy Study Results of Artemether-Lumefantrine on P. falciparum Infections (Sep. – Dec. 2004)
slide41
1. Artemether – Lumefantrine…

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)
ad