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Background Malaria incidence has declined in Ethiopia in the past 10 years. Current malaria diagnostic tests, including light microscopy and rapid antigen-detecting diagnostic tests (RDTs) cannot reliably detect low-density infections. Studies have shown that nucleic acid amplification tests are highly sensitive and specific in detecting malaria infection. This study took place with the aim of evaluating the performance of multiplex real time PCR for the diagnosis of malaria using patient samples collected from health facilities located at malaria elimination targeted low transmission settings in Ethiopia. Methods A health facility-based, cross-sectional survey was conducted in selected malaria sentinel sites. Malaria-suspected febrile outpatients referred to laboratory for malaria testing between December 2019 and March 2020 was enrolled into this study. Sociodemographic information and capillary blood samples were collected from the study participants and tested at spot with RDTs. Additionally, five circles of dry blood spot (DBS) samples on Whatman filter paper and thick and thin smear were prepared for molecular testing and microscopic examination, respectively. Multiplex real time PCR assay was performed at Ethiopian Public Health Institute (EPHI) malaria laboratory. The performance of multiplex real time PCR assay, microscopy and RDT for the diagnosis of malaria was compared and evaluated against each other. Results Out of 271 blood samples, multiplex real time PCR identified 69 malaria cases as Plasmodium falciparum infection, 16 as Plasmodium vivax and 3 as mixed infections. Of the total samples, light microscopy detected 33 as P. falciparum, 18 as P. vivax, and RDT detected 43 as P. falciparum, 17 as P. vivax, and one mixed infection. Using light microscopy as reference test, the sensitivity and specificity of multiplex real time PCR were 100% (95% CI (93–100)) and 83.2% (95% CI (77.6–87.9)), respectively. Using multiplex real time PCR as a reference, light microscopy and RDT had sensitivity of 58% (95% CI 46.9–68.4) and 67% (95% CI 56.2–76.7); and 100% (95% CI 98–100) and 98.9% (95% CI 96–99.9), respectively. Substantial level of agreement was reported between microscopy and multiplex real time PCR results with kappa value of 0.65. Conclusions Multiplex real-time PCR had an advanced performance in parasite detection and species identification on febrile patients’ samples than did microscopy and RDT in low malaria transmission settings. It is highly sensitive malaria diagnostic method that can be used in malaria elimination programme, particularly for community based epidemiological samples. Although microscopy and RDT had reduced performance when compared to multiplex real time PCR, still had an acceptable performance in diagnosis of malaria cases on patient samples at clinical facilities.

Dengue Fever (DF) is an important arthropod-borne viral infection, which has repeatedly oc-curred as outbreaks in eastern and northeastern Ethiopia since 2013. A cross-sectional epidemio-logical outbreak investigation was carried out from September - November 2019 on febrile pa-tients (confirmed malaria negative) who presented with suspected and confirmed DF at both public and private health facilities in Gewane District, Afar Region, northeastern Ethiopia. Ento-mological investigation of containers found in randomly selected houses belonging to DF positive patients was undertaken, to survey for the presence of Aedes larvae or pupae. A total of 1185 DF cases was recorded from six heath facilities during the 3-month study period. The mean age of DF cases was 27.2 years and 42.7% of the cases were female. The most affected age group was 15-49 years (78.98%). However, the attack rate (AR) was highest in the 49+ age group (134.2). A total of 162 artificial containers were inspected from 62 houses, with 49.4% found positive for Aedes larva/pupae. Aedes mosquitoes were mostly found breeding in buckets/bowls, clay jars, plastic tanks, and tires. World Health Organization entomological indices classified the study site as high risk for dengue outbreaks (House Index=45.2%, Container Index=49.4% and Breteau In-dex=129). Study findings highlight the importance of vector control to prevent future dengue out-breaks in the region. The scarcity of drinking water and changing climactic conditions may have also contributed to the occurrence of this outbreak.

Background In Ethiopia, malaria cases are declining as a result of proven interventions, and in 2017 the country launched a malaria elimination strategy in targeted settings. Accurate malaria diagnosis and prompt treatment are the key components of the strategy to prevent morbidity and stop the continuation of transmission. However, the quality of microscopic diagnosis in general is deteriorating as malaria burden declines. This study was carried out to evaluate the competency of microscopists and the performance of health facilities on malaria microscopic diagnosis. Methods A cross-sectional study was conducted from 1 August to 30 September, 2019 in 9 regional states and one city administration. A standard checklist was used for on-site evaluation, archived patient slides were re-checked and proficiency of microscopists was tested using a WHO-certified set of slides from the national slide bank at the Ethiopian Public Health Institute (EPHI). The strength of agreement, sensitivity, specificity, and positive and negative predictive values were calculated. Results In this study, 102 health facilities (84 health centres and 18 hospitals) were included, from which 202 laboratory professionals participated. In slide re-checking, moderate agreement (agreement (A): 76.0%; Kappa (K): 0.41) was observed between experts and microscopists on malaria detection in all health facilities. The sensitivity and specificity of routine slide reading and the re-checking results were 78.1 and 80.7%, respectively. Likewise, positive predictive value of 65.1% and negative predictive value of 88.8% were scored in the routine diagnosis. By panel testing, a substantial overall agreement (A: 91.8%; K: 0.79) was observed between microscopists and experts in detecting malaria parasites. The sensitivity and specificity in the detection of malaria parasites was 92.7 and 89.1%, respectively. In identifying species, a slight agreement (A: 57%; K: 0.18) was observed between microscopists and experts. Conclusion The study found significant false positive and false negative results in routine microscopy on slide re-checking of Plasmodium parasites. Moreover, reduced grade in parasite species identification was reported on the panel tests. Implementing comprehensive malaria microscopy mentorship, in-service training and supportive supervision are key strategies to improve the overall performance of health facilities in malaria microscopy.

Background Encouraged by the previous success in malaria control and prevention strategies, the Ethiopian ministry of health launched malaria elimination with a stepwise approach by primarily targeting the low-transmission Districts and their adjacent areas/zones in order to shrink the country’s malaria map progressively. Hence, this community survey was conducted to establish baseline malaria information at the preliminary phase of elimination at targeted settings. Methods A community-based cross-sectional survey was conducted at 20 malaria-elimination targeted Districts selected from five Regional states and one city administration in Ethiopia. The GPS-enabled smartphones programmed with Open Data Kit were used to enumerate 9326 study households and collect data from 29,993 residents. CareStart™ Malaria PAN (pLDH) Rapid Diagnostic Tests (RDTs) were used for blood testing at the field level. Armpit digital thermometers were used to measure axillary temperature. Result Overall malaria prevalence by RDTs was 1.17% (339/28973). The prevalence at District levels ranged from 0.0 to 4.7%. The proportion of symptomatic cases (axillary temperature > 37.5oc) in the survey was 9.2% (2760/29993). Among the 2510 symptomatic individuals tested with RDTs, only 3.35% (84/2510) were malaria positive. The 75.2% (255/339) of all malaria positives were asymptomatic. Of the total asymptomatic malaria cases, 10.2% (26/255) were under-five children and 89.8% (229/255) were above 5 years of age. Conclusion The study shows a decrease in malaria prevalence compared to the reports of previous malaria indicator surveys in the country. The finding can be used as a baseline for measuring the achievement of ongoing malaria elimination efforts. Particularly, the high prevalence of asymptomatic individuals (0.88%) in these transmission settings indicates there may be sustaining hidden transmission. Therefore, active case detection with more sensitive diagnostic techniques is suggested to know more real magnitude of residual malaria in the elimination-targeted areas.

The Coronavirus pandemic is recording unprecedented deaths worldwide. The temporal distribution and burden of the disease varies from setting to setting based on economic status, demography and geographic location. A rapid increase in the number of COVID-19 cases is being reported in Africa as of June 2020. Ethiopia reported the first COVID-19 case on 13 March 2020. Limited molecular laboratory capacity in resource constrained settings is a challenge in the diagnosis of the ever-increasing cases and the overall management of the disease. In this article, the Ethiopian Public Health Institute (EPHI) shares the experience, challenges and prospects in the rapid establishment of one of its COVID-19 testing laboratories from available resources. The first steps in establishing the COVID-19 molecular testing laboratory were i) identifying a suitable space ii) renovating it and iii) mobilizing materials including consumables, mainly from the Malaria and Neglected Tropical Diseases (NTDs) research team at the EPHI. A chain of experimental design was set up with distinct laboratories to standardize the extraction of samples, preparation of the master mix and detection. At the commencement of sample reception and testing, laboratory contamination was among the primary challenges faced. The source of the contamination was identified in the master mix room and resolved. In summary, the established COVID-19 testing lab has tested more than 40,000 samples (August 2020) and is the preferred setting for research and training. The lessons learned may benefit the further establishment of emergency testing laboratories for COVID-19 and/or other epidemic/pandemic diseases in resource-limited settings.

Background: Despite the social and psychological influences posed by bedbugs, so far there is no pest control to aver their public health impacts in Ethiopia. In addition, bedbugs are assumed to compromise the effective utilization of chemical-based malaria vector control like mosquito nets. However, there is a paucity of evidence on the influences of bedbug infestation on long-lasting insecticidal nets (LLINs) utilization in rural settings like Kola Shara, south-west Ethiopia.Methods: A community-based longitudinal study was conducted between April and December 2017 in 330 households who obtained new LLINs. Socio-demographic, geolocation, bedbug infestation of LLINs and utilization status of the households was documented by trained data collectors. Descriptive statistics was employed to describe the findings.Result: Bedbug infestation and the subsequent removal net varied among each round. Although varying from month to month, there was a consistent decline in the number of nets in use. During round one and round two 11.8% (39/330) and 15.4% (51/330) nets were not in place, respectively. Moreover, the number of nets removed during round three increased to 30.6% (101/330) and a slight reduction to 27% (89/330) during round four. Both corrugated iron and thatched tukuls roof types (93.4%, 256/274 versus 92.9%, 52/56) had similar prevalence of bedbug infestation during the baseline survey, April 2017. Prevalence of bedbug infestation was similar for both types of floors, 89.4% (245/274) in mud and (89.1% (50/56) with plastic. The proportion of LLINs infested by bedbugs has shown an increasing trend (81.8%, 270/330; 93.3%, 308/330; 92.1%, 304/330; 94.5%, 312/330) during Rounds 1, 2, 3 and 4, respectively.Conclusion: The present study demonstrated the role of LLINs infestation by bedbug that not only discouraged its persistent utilization but also discarded too early in less than six months. It is recommendable to design integrated vector control options that address pests of public health significance for a collateral benefit in malaria control. Furthermore, similar studies might emphasize on varying epidemiological settings.

Failures of primaquine for the treatment of relapsed Plasmodium vivax malaria is a serious challenge to malaria elimination in Ethiopia, where P. vivax accounts for up to 40% of malaria infections. We report here occurrence of a total of 15 episodes of primaquine treatment failure for radical cure in three historical P. vivax malaria patients from Gambella, Ethiopia, during 8–16 months of follow-up in 1985–1987. The total primaquine doses received were 17.5 mg/kg, 25.8 mg/kg, and 35.8 mg/kg, respectively. These total doses are much higher than in previous reports of patients with treatment failure in Ethiopia and East Africa. The possibility of new infection was excluded for these cases as the treatment and follow-up were carried out in Addis Ababa, a malaria-free city. Recrudescences were unlikely, considering the short duration pattern of the recurrences. The cytochrome P450 2D6 (CYP2D6) status for these patients is unknown, but polymorphisms have been described in Ethiopia and may have contributed to primaquine treatment failures. It is suggested that further studies be carried out in Ethiopia to determine the prevalence and distribution of primaquine treatment failures in different ethnic groups, considering the impact of CYP2D6 polymorphisms and the potential value of increasing the primaquine dose to avoid relapse.

Background An accurate understanding of the geographical distributions of both soil-transmitted helminths (STHs; Ascaris lumbricoides, Trichuris trichiura, and the hookworms Necator americanus and Ancylostoma duodenale) and schistosomes (SCH; Schistosoma mansoni and S. haematobium) is pivotal to be able to effectively design and implement mass drug administration (MDA) programmes. The objective of this study was to provide up-to-date data on the distribution of both STH and SCH in Ethiopia to inform the design of the national control program and to be able to efficiently achieve the 75% MDA coverage target set by the WHO. Methods Between 2013 and 2015, we assessed the distributions of STH and SCH infections in a nationwide survey covering 153,238 school-aged children (aged 5–15 years), from 625 woredas (districts), representing all nine Regional States and two City Administrations of Ethiopia. Nationwide disease maps were developed at the woreda level to enable recommendations on the design of the national MDA programme. Results The prevalence of any STH infection across the study population was 21.7%, with A. lumbricoides (12.8%) being the most prevalent STH, followed by hookworms (7.6%) and T. trichiura (5.9%). The prevalence for any SCH was 4.0% in areas where both SCH species were evaluated. Schistosoma mansoni was the most prevalent SCH (3.5 vs 0.3%). STHs were more prevalent in southwest Ethiopia, whereas SCH was found mostly in the west and northeast of the country. The prevalence of moderate-to-heavy intensity infections was 2.0% for STHs and 1.6% for SCH. For STH, a total of 251 woredas were classified as moderately (n = 178) or highly endemic (n = 73), and therefore qualify for an annual and biannual MDA program, respectively. For SCH, 67 woredas were classified as endemic and 8 as highly endemic, and hence they require every two years and annual MDA programme, respectively. Conclusions The results confirm that Ethiopia is endemic for both STHs and SCH, posing a significant public health problem. Following the WHO recommendations on mass drug administration, 18 and 14 million school-aged children are in need of MDA for STHs and SCH, respectively, based on the number of SACs that live on the eligible geographical areas.

Additional file 1: Figure S1. Flow diagram of the survey organogram. Survey management and supervision was cascaded in such a way that the Ethiopian Public Health Institute team led and oversaw the whole survey. Regional States supervisors supported their respective teams. The overall mapping implementation was checked by external supervisors.

Although Ethiopia has an overall lower prevalence of Plasmodium falciparum among countries in Africa, the emergence of drug resistance could seriously hinder elimination efforts. Using samples collected from five therapeutic efficacy studies conducted in 2007-11, we evaluated the prevalence of putative drug resistance mutations in the pfcrt, pfmdr1, and kelch13 genes at the time of those studies, as well as the ama1 gene for genetic relatedness using a pooled amplicon deep sequencing approach. Among all sites, the kelch13 gene showed no mutations, whereas the pfcrt CVIET genotype was fixed in all populations. By contrast, the mdr1 gene demonstrated frequencies of resistant genotypes ranging from 10 to 100% at amino acid position 86 and from 0% to 57.8% at amino acid position 1246. Although we observed a low degree of haplotype sharing between sites, we did observe considerable haplotype sharing within sites over time. This suggests that P. falciparum populations in Ethiopia are isolated and able to persist through time.

Purpose: Following the increased Plasmodium falciparum resistance to chloroquine and sulfadoxine/pyrimethamine, Ethiopia adopted artemether/lumefantrine (AL) as the first-line treatment for uncomplicated P.falciparum in 2004.According to the recommendation of the World Health Organization, this study was carried out for regular monitoring of the efficacy of AL in treating the uncomplicated P.falciparum malaria in Metema district, Gondar Zone, Northwest Ethiopia.Patients and methods: This is a one-arm prospective 28-day in vivo therapeutic efficacy study among the uncomplicated P.falciparum malaria patients aged 6 months and older.The study was conducted from October 2014 to January 2015, based on the revised World Health Organization protocol of 2009 for surveillance of antimalarial drug therapeutic efficacy study.Standard six-dose regimen of AL was given twice daily for 3 days, and then the treatment outcomes were assessed on days 0, 1, 2, 3, 7, 14, 21, 28, and any other unscheduled day for emergency cases.Results: There were 91 study subjects enrolled in this study, of whom 80 study subjects completed the full follow-up schedules and showed adequate clinical and parasitological responses on day 28, with no major adverse event.Per protocol analysis, the unadjusted cure rate of Coartem® was 98.8% (95% confidence interval: 93.3%-100%) in the study area.Recurrence of one P.falciparum case was detected on day 28, with a late parasitological failure rate of 1.2%.No early treatment failure occurred.Complete parasite and fever clearance was observed on day 3.Gametocyte carriage was 4.4% at enrollment that cleared on day 21.Although the difference is statistically not significant, a slight increase in the level of mean hemoglobin from baseline to day 28 was observed.Conclusion: The study showed high efficacy and tolerability of Coartem® against uncomplicated P.falciparum malaria, suggesting the continuation as a first-line drug in the study district.However, regular monitoring of the therapeutic efficacy of the drug, possibly with plasma drug-level measurement, is critical among the mobile border population.

Background The goal of the global lymphatic filariasis (LF) program is to eliminate the disease as a public health problem by the year 2020. The WHO mapping protocol that is used to identify endemic areas in need of mass drug administration (MDA) uses convenience-based sampling. This rapid mapping has allowed the global program to dramatically scale up treatment, but as the program approaches its elimination goal, it is important to ensure that all endemic areas have been identified and have received MDA. In low transmission settings, the WHO mapping protocol for LF mapping has several limitations. To correctly identify the LF endemicity of woredas, a new confirmatory mapping tool was developed to test older school children for circulating filarial antigen (CFA) in settings where it is uncertain. Ethiopia is the first country to implement this new tool. In this paper, we present the Ethiopian experience of implementing the new confirmatory mapping tool and discuss the implications of the results for the LF program in Ethiopia and globally. Methods Confirmatory LF mapping was conducted in 1,191 schools in 45 woredas, the implementation unit in Ethiopia, in the regions of Tigray, Amhara, Oromia, SNNP, Afar and Harari, where the results of previous mapping for LF using the current WHO protocol indicated that LF endemicity was uncertain. Within each woreda schools were selected using either cluster or systematic sampling. From selected schools, a total of 18,254 children were tested for circulating filarial antigen (CFA) using the immuno-chromatographic test (ICT). Results Of the 18,254 children in 45 woredas who participated in the survey, 28 (0.16%) in 9 woredas tested CFA positive. According to the confirmatory mapping threshold, which is ≥2% CFA in children 9–14 years of age, only 3 woredas out of the total 45 had more CFA positive results than the threshold and thus were confirmed to be endemic; the remaining 42 woredas were declared non-endemic. These results drastically decreased the estimated total population living in LF-endemic woredas in Ethiopia and in need of MDA by 49.1%, from 11,580,010 to 5,893,309. Conclusion This study demonstrated that the new confirmatory mapping tool for LF can benefit national LF programs by generating information that not only can confirm where LF is endemic, but also can save time and resources by preventing MDA where there is no evidence of ongoing LF transmission., Author summary Lymphatic filariasis (LF) is a mosquito-borne parasitic disease, caused by 3 nematode parasites, Wuchereria bancrofti, Brugia malayi and Brugia timori. The aim of the Global Program to Eliminate LF (GPELF) is to interrupt LF transmission through mass drug administration (MDA) by 2020 and to alleviate the suffering of affected people. Mapping is the first programmatic step to determining areas of LF endemicity and establishing a national program. Ethiopia was believed to be endemic for LF, but until recently the distribution of LF in the country was unknown. From 2008–2013, mapping for LF was conducted using the current WHO protocol, and 112 woredas were identified as endemic or possibly endemic. In 45 of these 112 woredas, only a single CFA positive result was found (

Background Long-lasting insecticidal nets (LLINs) are a key malaria control intervention. Although LLINs are presumed to be effective for 3 years under field or programmatic conditions, net care and repair approaches by users influence the physical and chemical durability. Understanding how knowledge, perception and practices influence net care and repair practices could guide the development of targeted behavioural change communication interventions related to net care and repair in Ethiopia and elsewhere. Methods This population-based, household survey was conducted in four regions of Ethiopia [Amhara, Oromia, Tigray, Southern Nations Nationalities Peoples Region (SNNPR)] in June 2015. A total of 1839 households were selected using multi-stage sampling procedures. The household respondents were the heads of households. A questionnaire was administered and the data were captured electronically. STATA software version 12 was used to analyse the data. Survey commands were used to account for the multi-stage sampling approach. Household descriptive statistics related to characteristics and levels of knowledge and perception on net care and repair are presented. Ordinal logistic regression was used to identify factors associated with net care and repair perceptions. Results Less than a quarter of the respondents (22.3%: 95% CI 20.4–24.3%) reported adequate knowledge of net care and repair; 24.6% (95% CI 22.7–26.5%) of the respondents reported receiving information on net care and repair in the previous 6 months. Thirty-five per cent of the respondents (35.1%: 95% CI 32.9–37.4%) reported positive perceptions towards net care and repair. Respondents with adequate knowledge on net care and repair (AOR 1.58: 95% CI 1.2–2.02), and those who discussed net care and repair with their family (AOR 1.47: 95% CI 1.14–1.89) had higher odds of having positive perceptions towards net care and repair. Conclusions The low level of reported knowledge on net care and repair, as well as the low level of reported positive perception towards net repair need to be addressed. Targeted behavioural change communication campaigns could be used to target specific groups; increased net care and repair would lead to longer lasting nets. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2043-1) contains supplementary material, which is available to authorized users.

Additional file 1. Statement used to measure overall perception towards net care and repair.

Climate change and variability are the main drivers of several infectious and non-infectious diseases that are of great public health importance in Ethiopia. Malaria, yellow fever, dengue fever, meningitis, leishmaniosis, and different forms of diarrheal diseases are the most common climate sensitive diseases. The Health Vulnerability Index (HVI) assessment is adopted from Livelihood Vulnerability Index (LVI-IPCC). It considers the three IPCC contributing factors to vulnerability: exposure, adaptive capacity, and sensitivity as major factors along the nine profiles/determinants using secondary data from published documents. The values for the exposure levels ranged from 0.12 to 0.69 and grouped the regions into moderately exposed and highly exposed regions to climate change. All regions are found highly sensitive to climate change induced diseases with the exception of Addis Ababa. Adaptive capacity measured in terms of several socio-economic factors such as finance, infrastructure, available health professionals and social determinants of health reveals variation between regions characterized as urban and the rest. HVI values range from less vulnerable (−0.247) to highly vulnerable (0.279). The analysis categorized regions into relatively least vulnerable (0.6%), moderately vulnerable (49.95%), highly vulnerable (10.35%) and very high vulnerable (39.5%) of the total land mass. Health adaptation strategies recommended include improved public health surveillance systems; establishing health and climate data management system; strengthening early warning systems; improved public health services; improved water, sanitation, and hygiene system; human resource development; enhanced public awareness and attitudes; targeted intervention to regional contexts by enhanced financial resources.

Objective: The aim of this study was to investigate malaria elimination in Ethiopia. Ethiopia has planned to eliminate malaria by 2015 in areas of unstable malaria transmission and in the entire country by 2020. However, there is a shortage and maldistribution of the health workforce in general and malaria experts in particular. Training, motivating, and retaining the health workforce involved in malaria control is one strategy to address the shortage and maldistribution of the health workforce to achieve the goal of elimination.Methods: Policy options include the following: (i) in-service training (educational outreach visits, continuing education meetings and workshops, audit and feedback, tailored interventions, and guideline dissemination) may improve professional practice; (ii) recruiting and training malaria specialists together with academic support, career guidance, and social support may increase the number of malaria experts; and (iii) motivation and retention packages (such as financial, educational, personal, and professional support incentives) may help motivate and retain malaria professionals.Results: Implementation strategies include the following: (i) massive training of health personnel involved in malaria elimination and malaria experts (requiring special training) at different levels (national, sub-national, District & community levels), and (ii) recruiting highly qualified health personnel and retention and motivation mechanisms are needed.Conclusions: The lack of adequately trained human resources and personnel attrition are major challenges to effectively implement the planned multi-faceted malaria elimination by 2020 strategy in Ethiopia. Although a reduction in malaria incidence has been observed in the last 3-4 years, maintaining this success and achieving the malaria elimination goal with the present human resource profile will be impossible. A clear strategy for developing the capacity of the health workers in general, and malaria experts in particular, and retaining and motivating staff are crucial for malaria control and elimination.

Purpose Following the increased Plasmodium falciparum resistance to chloroquine and sulfadoxine/pyrimethamine, Ethiopia adopted artemether/lumefantrine (AL) as the first-line treatment for uncomplicated P. falciparum in 2004. According to the recommendation of the World Health Organization, this study was carried out for regular monitoring of the efficacy of AL in treating the uncomplicated P. falciparum malaria in Metema district, Gondar Zone, Northwest Ethiopia. Patients and methods This is a one-arm prospective 28-day in vivo therapeutic efficacy study among the uncomplicated P. falciparum malaria patients aged 6 months and older. The study was conducted from October 2014 to January 2015, based on the revised World Health Organization protocol of 2009 for surveillance of antimalarial drug therapeutic efficacy study. Standard six-dose regimen of AL was given twice daily for 3 days, and then the treatment outcomes were assessed on days 0, 1, 2, 3, 7, 14, 21, 28, and any other unscheduled day for emergency cases. Results There were 91 study subjects enrolled in this study, of whom 80 study subjects completed the full follow-up schedules and showed adequate clinical and parasitological responses on day 28, with no major adverse event. Per protocol analysis, the unadjusted cure rate of Coartem® was 98.8% (95% confidence interval: 93.3%–100%) in the study area. Recurrence of one P. falciparum case was detected on day 28, with a late parasitological failure rate of 1.2%. No early treatment failure occurred. Complete parasite and fever clearance was observed on day 3. Gametocyte carriage was 4.4% at enrollment that cleared on day 21. Although the difference is statistically not significant, a slight increase in the level of mean hemoglobin from baseline to day 28 was observed. Conclusion The study showed high efficacy and tolerability of Coartem® against uncomplicated P. falciparum malaria, suggesting the continuation as a first-line drug in the study district. However, regular monitoring of the therapeutic efficacy of the drug, possibly with plasma drug-level measurement, is critical among the mobile border population.

Background: As per the WHO recommendation, the development of resistance by P. falciparum to most artemisinin combination therapies (ACTs) triggered the need for routine monitoring of the efficacy of the drugs every two years in all malaria endemic countries. Hence, this study was carried out to assess the therapeutic efficacy of Artemether-Lumefantrine (Coartem®) in treating the uncomplicated falciparum malaria, after 9 years of its introduction in the Metehara, Eastern Ethiopia. Method: This is part of the therapeutic efficacy studies by the Federal Ministry of Health Ethiopia, which were conducted in regionally representative sentinel sites in the country from October 2014 to January 2015. Based on the study criteria set by WHO, febrile and malaria suspected outpatients in the health center were consecutively recruited to study. A standard six-dose regimen of AL was administered over three days and followed up for measuring therapeutic responses over 28 days. Data entry and analysis was done by using the WHO designed Excel spreadsheet and SPSS version 20 for Windows. Statistical significant was considered for P-value less than 0.05. Result: Of the 91 patients enrolled, the day-28 analysis showed 83 adequate clinical and parasitological responses (ACPRs). Per protocol analysis, PCR-uncorrected & corrected cure rates of Coartem® among the study participants were 97.6% (95%CI: 93.6-99.5) and 98.8% (CI: 93.5-100%), respectively. No parasite detected on day 3 and onwards. Fever clearance was above 91% on day-3. Mean hemoglobin was significantly increased (P

Background Plasmodium vivax malaria is a major cause of morbidity and recognised as an important contributor to mortality in some endemic areas. The current recommended treatment regimen for the radical cure of P. vivax includes a schizontocidal antimalarial, usually chloroquine, combined with a 14 day regimen of primaquine. The long treatment course frequently results in poor adherence and effectiveness. Shorter courses of higher daily doses of primaquine have the potential to improve adherence and thus effectiveness without compromising safety. The proposed multicentre randomised clinical trial aims to provide evidence across a variety of endemic settings on the safety and efficacy of high dose short course primaquine in glucose-6-phosphate-dehydrogenase (G6PD) normal patients. Design This study is designed as a placebo controlled, double blinded, randomized trial in four countries: Indonesia, Vietnam, Afghanistan and Ethiopia. G6PD normal patients diagnosed with vivax malaria are randomized to receive either 7 or 14 days high dose primaquine or placebo. G6PD deficient (G6PDd) patients are allocated to weekly primaquine doses for 8 weeks. All treatment is directly observed and recurrent episodes are treated with the same treatment than allocated at the enrolment episode. Patients are followed daily until completion of treatment, weekly until 8 weeks and then monthly until 1 year after initiation of the treatment. The primary endpoint is the incidence rate (per person year) of symptomatic recurrent P. vivax parasitaemia over 12 months of follow-up, for all individuals, controlling for site, comparing the 7 versus 14-day primaquine treatment arms. Secondary endpoints are other efficacy measures such as incidence risk at different time points. Further endpoints are risks of haemolysis and severe adverse events. Discussion This study has been approved by relevant institutional ethics committees in the UK and Australia, and all participating countries. Results will be disseminated to inform P. vivax malaria treatment policy through peer-reviewed publications and academic presentations. Findings will contribute to a better understanding of the risks and benefits of primaquine which is crucial in persuading policy makers as well as clinicians of the importance of radical cure of vivax malaria, contributing to decreased transmission and a reduce parasite reservoir. Trial registration ClinicalTrials.gov Identifier: NCT01814683. Registered March 18, 2013 Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1276-2) contains supplementary material, which is available to authorized users.

The project “Ethiopian Malaria Prediction System” implemented from 2007 to 2012 combined new population-based malaria transmission information with climate and land use variability data to develop an early warning tool to predict malaria epidemics in Ethiopia. Scientists from Ethiopia and Norway collaborated to incorporate climate variability and forecast information for malaria epidemics. Our study shows that the association between weather and malaria is complex. Statistical models can predict malaria for large areas. However, as malaria transmission varies and depends on local environmental conditions, we need to have good and local knowledge about each area. However, weather variability is the main driver of malaria in Ethiopia. While the generation of precipitation depends on local ascent and cooling of the air, our research provided new data on the transport of moisture into the country that may improve weather forecasting. We developed a new classification of climate zones, have mapped drought episodes in Ethiopia during the last decades, and have improved seasonal weather forecasting. Our hydrology studies show that potential climate change differs among the Ethiopian river basins, with river flows being sensitive to variations in rainfall, and less to temperature changes. The computer model, Open Malaria Warning, incorporates hydrological, meteorological, mosquito-breeding, land-use data, and cattle densities to find out when and where outbreaks are likely to occur. We validated the model with data for malaria transmission in the highlands and lowlands, characterizing malaria transmission over some years in both highlands and lowlands. This provided us with new knowledge on malaria transmission in Ethiopia, how intense the seasonal transmission is, and how malaria occurs in different populations and areas. Our study showed that indigenous malaria transmission during a non-epidemic year takes place above 2000 m altitude. We also showed the ideal temperature for malaria transmission is about 25°C, underlining that global warming may lead to increased risk of malaria in highland areas, and less in the lowlands with already high average temperatures. However, to validate such models, there is a need for several years of active monitoring of malaria cases and mosquito densities. Unfortunately, such data is rare in Africa, and we need to invest in long-term monitoring of malaria transmission.

Background The genetic diversity of Plasmodium falciparum has been extensively studied in various countries. However, limited data are available from Ethiopia. This study was conducted to evaluate the extent of genetic diversity of P. falciparum in Kolla-Shele, in the southwest of Ethiopia. Methods A total of 88 isolates from patients with uncomplicated P. falciparum attending Kolla-Shele Health Centre was collected from September to December, 2008. After extraction of DNA by Chelex® method, the samples were genotyped by using nested-PCR of msp1 (block 2) and msp2 (block 3) including their allelic families: K1, MAD20, RO33 and FC27, 3D7/IC1, respectively. Results Allelic variation in both msp1 and msp2 were identified in the 88 blood samples. For msp1 67% (59/88) and msp2 44% (39/88) were observed. K1 was the predominant msp1 allelic family observed in 33.9% (20/59) of the samples followed by RO33 and MAD20. Of the msp2 allelic family 3D7/IC1 showed higher frequency (21.5%) compared to FC27 (10.3%). A total of twenty-three alleles were detected; of which, eleven were from msp2 and twelve from msp2 genes. Fifty-nine percent of isolates had multiple genotypes and the overall mean multiplicity of infection was 1.8 (95% CI: 1.48-2.04). The heterozygosity index was 0.79 and 0.54for msp1 and msp2, respectively. There was no statically significant difference in the multiplicity of infection by either age or parasite density (P > 0.05). Conclusion This genetic diversity study showed the presence of five allelic types in the study area, with dominance K1 in the msp1 family and 3D7/IC1 in the msp2 family. Multiple infections were observed in nearly 60% of the samples. Electronic supplementary material The online version of this article (doi:10.1186/s12936-015-0604-8) contains supplementary material, which is available to authorized users.

Background The highlands of Ethiopia, situated between 1,500 and 2,500 m above sea level, experienced severe malaria epidemics. Despite the intensive control attempts, underway since 2005 and followed by an initial decline, the disease remained a major public health concern. The aim of this study was to identify malaria risk factors in highland-fringe south-central Ethiopia. Methods This study was conducted in six rural kebeles of Butajira area located 130 km south of Addis Ababa, which are part of demographic surveillance site in Meskan and Mareko Districts, Ethiopia. Using a multistage sampling technique 750 households was sampled to obtain the 3,398 people, the estimated sample size for this study. Six repeated cross-sectional surveys were conducted from October 2008 to June 2010. Multilevel, mixed-effects logistic regression models fitted to Plasmodium infection status (positive or negative) and six variables. Both fixed- and random-effects differences in malaria infection were estimated using median odds ratio and interval odds ratio 80%. The odds ratios and 95% confidence intervals were used to estimate the strength of association. Results Overall, 19,207 individuals were sampled in six surveys (median and inter-quartile range value three). Six of the five variables had about two-fold to eight-fold increase in prevalence of malaria. Furthermore, among these variables, October-November survey seasons of both during 2008 and 2009 were strongly associated with increased prevalence of malaria infection. Children aged below five years (adjusted OR= 3.62) and children aged five to nine years (adj. OR= 3.39), low altitude (adj. OR= 5.22), mid-level altitude (adj. OR= 3.80), houses with holes (adj. OR= 1.59), survey seasons such as October-November 2008 (adj. OR= 7.84), January-February 2009 (adj. OR= 2.33), June-July 2009 (adj. OR=3.83), October-November 2009 (adj. OR= 7.71), and January-February 2010 (adj. OR= 3.05) were associated with increased malaria infection.The estimates of cluster variances revealed differences in malaria infection. The village-level intercept variance for the individual-level predictor (0.71 [95% CI: 0.28-1.82]; SE=0.34) and final (0.034, [95% CI: 0.002-0.615]; SE=0.05) were lower than that of empty (0.80, [95% CI: 0.32-2.01]; SE=0.21). Conclusion Malaria control efforts in highland fringes must prioritize children below ten years in designing transmission reduction of malaria elimination strategy. publishedVersion

Malaria is a major public health problem in Ethiopia. Plasmodium falciparum and Plasmodium vivax co-exist and malaria rapid diagnostic test (RDTs) is vital in rendering parasite-confirmed treatment especially in areas where microscopy from 2008 to 2010 is not available. CareStartTM Malaria Pf/Pv combo test was evaluated compared to microscopy in Butajira area, south-central Ethiopia. This RDT detects histidine-rich protein-2 (HRP2) found in P. falciparum, and Plasmodium enzyme lactate dehydrogenase (pLDH) for diagnosis of P. vivax. The standard for the reporting of diagnostic accuracy studies was complied. Among 2,394 participants enrolled, 10.9% (n=87) were Plasmodium infected (household survey) and 24.5% (n=392) health facility-based using microscopy. In the household surveys, the highest positivity was caused by P. vivax (83.9%, n=73), P. falciparum (15.0%, n=13), and the rest due to mixed infections of both (1.1%, n=1). In health facility, P. vivax caused 78.6% (n=308), P. falciparum caused 20.4% (n=80), and the rest caused by mixed infections 1.0% (n=4). RDT missed 9.1% (n=8) in household and 4.3% (n=17) in health facility-based surveys among Plasmodium positive confirmed by microscopy while 3.3% (n=24) in household and 17.2% (n=208) in health facility-based surveys were detected false positive. RDT showed agreement with microscopy in detecting 79 positives in household surveys (n=796) and 375 positives in health centre survey (n=1,598). RDT performance varied in both survey settings, lowest PPV (64.3%) for Plasmodium and P. falciparum (77.2%) in health centres; and Plasmodium (76.7%) and P. falciparum (87.5%) in household surveys. NPV was low in P. vivax in health centres (77.2%) and household (87.5%) surveys. Seasonally varying RDT precision of as low as 14.3% PPV (Dec. 2009), and 38.5% NPV (Nov. 2008) in health centre surveys; and 40-63.6% PPV was observed in household surveys. But the influence of age and parasite density on RDT performance was not ascertained. Establishing quality control of malaria RDT in the health system in areas with low endemic and where P. falciparum and P. vivax co-exist is recommendable. CareStartTM RDT might be employed for epidemiological studies that require interpreting the results cautiously. Future RDT field evaluation against microscopy should be PCR corrected. publishedVersion

Malaria in Ethiopia is one of the leading causes of death(21.8 percent), consultation in outpatient departments (17.8percent) and hospital admissions (14.1 percent) (2;14).To overcome this problem, the Malaria Control Program(Federal Ministry of Health) has designed a community-based malaria treatment approach that played key roles inmalaria epidemic control and community mobilization aswell as vector control operations. In this approach, Commu-nity Health Workers (CHWs) and Village Malaria Workers,volunteers selected by community and trained on malaria di-agnosis and treatment as well as indoor residual spray forfew days (16). However, sustainability of this approach hasbeen a challenge to the malaria control program. Thus, in-stitutional arrangements in which every Kebele (the smallestadministrative unit of 5,000 people) has a health post staffedbytwoHealthExtensionWorkers(HEW)aspartofthecoun-try’s health system is a breakthrough to strengthen malariacontrol. A study has shown that more than half of the patientswith fever visitCHWs and private health facilityservices (4).In Ethiopia, unlike in many parts of Africa

Background: Insecticide treated mosquito nets (ITNs) have raised a renewed interest to serve as tools for malaria control in Africa. The use of this control method has been proved to be a cost-effective means for the control of malaria. However, little is known the acceptability and utilization of mosquito nets in Ethiopia. Objectives: The objective of this study is to provide relevant information about the knowledge, attitude and experience of communities about malaria and its preventive methods, particularly the acceptability and affordability of ITNs. Methods: A descriptive cross-sectional study was carried out in five different parts of Ethiopia in January and February 1999. A multi-stage sampling method was used to select 1,933 households for the study. Data were collected by interviewing household heads or their representatives. Results: Ninety-five percent of the participants perceived fever, headache and chilling of the body as the main symptoms of malaria. More than 87% of the interviewees correctly identified the names of the anti-malarial drugs, chloroquine and SP. About 93% of the participants knew that malaria could be transmitted through mosquito bites. Mosquitoes are known to breed on stagnant water (83%). More than 43% of the respondents replied that DDT, in combination with other control measures, could prevent malaria. Forty-one percent of the respondents had heard about the mosquito net. Only 5.3% of the respondents in the survey reported the presence of at least one mosquito net in their households. Most of the respondents (92.5%) were interested in using mosquito nets sometime in the future. The most preferred mode of obtaining ITNs was on loan basis (60%). Accordingly, 24%, 20% and 16% were willing to pay in three, six, and nine months of installments and above, respectively. Forty-percent of the study participants were ready to buy it in cash. Of the 1,696 respondents, 47% suggested 10 Birr or less, 11% between 11 and 20 Birr, 28% from 2150 Birr and the rest (14%) mentioned 51 Birr and above as the appropriate price for purchasing a single ITN. Conclusion: The utilization of mosquito nets at the time of the study was very low. However, acceptability and willingness to use ITNs for malaria prevention was very high. Thus, the expanding ITN implementation and increasing its coverage for malaria control both in urban and rural malarious areas of the country is crucial. It is recommended that communities should be strongly sensitized on the importance of ITNs for malaria control and the availability and affordability should be insured. [Ethiop.J.Health Dev. 2005;19(1):16-23]

Malaria is a major public health problem and of considerable socio-economic burden in most parts of Ethiopia. The country has witnessed recurrent epidemics of the disease, resulting in grave consequences including in areas designated as highland fringe. A study was undertaken to grossly assess the magnitude of the problems, the effectiveness of the control options and to explore the challenges encountered and the experiences gained during the 1998 malaria epidemic in Akaki Town and its environs. Health facility clinical records of individual patients and weekly surveillance and epidemic control reports were utilized as principal sources of data. The information revealed that the epidemic was very alarming affecting a sizable part of Akaki and the surrounding areas, with the total number of cases amounting to 622. The epidemic was controlled by case detection and treatment as well as by intensive vector control activities. The control endeavor, however, posed great difficulties due to the absence of systematic malaria control program, owing to underestimation of the threat from highland malaria. The contribution from the adjacent Oromia Malaria Control Program and The Federal Ministry of Health to control the epidemic (mainly vector control) was reckoned to be substantial. Thus, capacity building targeted to early detection, prevention and control of malaria epidemics, and preparedness is deemed to be of paramount importance. A viable Integrated Disease Surveillance and Response at health facilities could ensure early containment of the otherwise devastating epidemics.

Background: In recent years malaria is becoming endemic in highland areas beyond its previously known upper limit of transmission. Assessment of the situation of the disease in such areas is necessary in order to institute appropriate control activities. Objectives: The objectives of the study were to determine the prevalence of malaria, the parasite species involved and Anopheles species responsible in local malaria transmission. Methods: A systematic sampling technique was used to select survey households. Blood films were collected monthly between October and December 1999 from all household members by a trained and experienced laboratory technician. Larval and adult mosquitoes were monthly collected using different methods from September 1999 to October 2000. Results: Among 2136 examined blood films, 78(3.7%) of them were malaria positive of which 54(69%) were due to Plasmodium vivax and 24 (31%) due to P. falciparum. Anopheles gambiae s. l. (presumably An. arabiensis ) and An. christyi were the dominant man-biting species, with the former being the major vector in the area. Both these species were found to be more of exophagic and active in the early evening, unlike An. pharoensis , which showed an endophagic tendency. Conclusion: This study indicated that indigenous transmission of malaria occurs in the study area. Transmission is reckoned to be maintained by low density of vector species for short period of time under favorable conditions. Therefore, the acquisition of communal immunity is interrupted by long duration of non-malaria season leading to the occurrence of recurrent malaria epidemics. [ Ethiop.J.Health Dev . 2004;18(1):2-7]