1

Malaria Malaria Prevention and Prevention and

Control in Control in EthiopiaEthiopia

Dr Daddi JimaDr Daddi Jima

National Malaria Control Program, EthiopiaNational Malaria Control Program, Ethiopia

2

History of Malaria control History of Malaria control organizationorganization

1959 - Malaria Eradication Service 1959 - Malaria Eradication Service

establishedestablished One year after major malaria epidemicOne year after major malaria epidemic

1971 - Vertical Malaria Control 1971 - Vertical Malaria Control

ProgramProgram

1993 – Malaria control was integrated 1993 – Malaria control was integrated

into general health system and into general health system and

decentralized decentralized

3

Malaria EpidemiologyMalaria Epidemiology

75% of the land ( areas below 2000 m 75% of the land ( areas below 2000 m above sea level) is malarious above sea level) is malarious Fertile low land areasFertile low land areas Suitable for agricultureSuitable for agriculture

>50 million (68%) of the population live >50 million (68%) of the population live in these areas and at risk of malariain these areas and at risk of malaria

Transmission is unstable and seasonalTransmission is unstable and seasonal September to December and April to MaySeptember to December and April to May Coincide with major planting and Coincide with major planting and

harvesting season for farmers - aggravate harvesting season for farmers - aggravate economic losseconomic loss

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Malaria EpidemiologyMalaria Epidemiology Major epidemics occur every 5 - 8 Major epidemics occur every 5 - 8

years, but focal epidemics are years, but focal epidemics are happen every year,happen every year,

Two parasite species Two parasite species Plasmodium falciparumPlasmodium falciparum (60%) (60%) P. vivaxP. vivax (40%) (40%)

Main malaria vector Main malaria vector Anopheles arabiansisAnopheles arabiansis Anopheles pharoensisAnopheles pharoensis

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Malaria BurdenMalaria Burden Malaria is a major public health Malaria is a major public health

problem in Ethiopia problem in Ethiopia Every year it is the leading cause of Every year it is the leading cause of

out patient consultations, admissions out patient consultations, admissions and deathand death

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Malaria BurdenMalaria Burden

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Malaria BurdenMalaria Burden

8

The goal of malaria The goal of malaria prevention and control in prevention and control in

EthiopiaEthiopia To contribute to MDG 6 target 8 by To contribute to MDG 6 target 8 by

reducing the overall burden of malaria reducing the overall burden of malaria by 50% by the year 2010by 50% by the year 2010

ANDAND To contribute to the reduction of child To contribute to the reduction of child

mortality (MDG 4) and improvement of mortality (MDG 4) and improvement of maternal health (MDG 5)maternal health (MDG 5)

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Malaria prevention and control Malaria prevention and control strategiesstrategies

1) Main strategies1) Main strategies:: Early diagnosis and effective treatmentEarly diagnosis and effective treatment Vector controlVector control

Insecticide treated netsInsecticide treated nets Indoor Residual SprayIndoor Residual Spray

Epidemic prevention and controlEpidemic prevention and control

2)2) Cross cutting Strategies:Cross cutting Strategies: Human resource development Human resource development Operational research Operational research Information, education and Information, education and

communicationcommunication Program monitoring and evaluation Program monitoring and evaluation

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Government policy towards malaria control in Government policy towards malaria control in Ethiopia:Ethiopia:

Priority to communicable Priority to communicable diseasesdiseases

Free diagnosis (especially at Free diagnosis (especially at lower health facilities level)lower health facilities level)

Free anti-malarial drugsFree anti-malarial drugsFree distribution of ITNs to allFree distribution of ITNs to allFree indoor residual spraying of Free indoor residual spraying of

houseshouses

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Malaria Diagnosis & TreatmentMalaria Diagnosis & Treatment Diagnosis:Diagnosis:

Clinical, Rapid diagnostic tests and Clinical, Rapid diagnostic tests and MicroscopyMicroscopy

Treatment Treatment 11stst line - Artemether-Lumefantrine line - Artemether-Lumefantrine

(Coartem®) for (Coartem®) for P.falciparumP.falciparum and CQ and CQ for for P.vivaxP.vivax

Quinine for pregnant women & children Quinine for pregnant women & children <5kg<5kg

22ndnd line treatment – quinine tablets line treatment – quinine tablets Severe malaria – quinine injectionSevere malaria – quinine injection

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Indoor Residual SprayingIndoor Residual Spraying

Indoor residual spraying has Indoor residual spraying has been implemented in Ethiopia been implemented in Ethiopia for more than 4 decades. for more than 4 decades.

The insecticide used is DDT 75% The insecticide used is DDT 75%

Every year 20% – 30% of Every year 20% – 30% of sprayable localities coveredsprayable localities covered

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Distribution started with Distribution started with ordinary nets since 1998ordinary nets since 1998 Coverage and re-impregnation rate Coverage and re-impregnation rate

was lowwas low LLINs introduced in 2005LLINs introduced in 2005

Rapid scale- up was carried out Rapid scale- up was carried out GFATM and other donorsGFATM and other donors

2 nets per household2 nets per household 20 mln nets needed to cover all20 mln nets needed to cover all

Use of insecticide Use of insecticide treated netstreated nets

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Major Achievements: Diagnosis and Major Achievements: Diagnosis and TreatmentTreatment

Target: Universal coverage of fever Target: Universal coverage of fever treatment within 24 hours of onset in 2008treatment within 24 hours of onset in 2008 Diagnosis and treatment guideline revisedDiagnosis and treatment guideline revised RDT procurement and distribution (>2 million RDT procurement and distribution (>2 million

tests)tests) Coartem procured and distributed (> 6 million Coartem procured and distributed (> 6 million

doses every year for the last 2 years)doses every year for the last 2 years) OpportunityOpportunity

Accelerated expansion of primary health service Accelerated expansion of primary health service coverage - universal health service coverage by coverage - universal health service coverage by 20082008

Health extension programHealth extension program Better financial input: GFATM, PMI Better financial input: GFATM, PMI

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Major Achievements: LLINsMajor Achievements: LLINs

Target: to cover all households in Target: to cover all households in malarious areas with at lease 2 nets malarious areas with at lease 2 nets per household (20 million nets) in per household (20 million nets) in 2007 and to protect more than 50 2007 and to protect more than 50 million people.million people.

18.2 million LLINs have been 18.2 million LLINs have been distributed to beneficiaries since 2005distributed to beneficiaries since 2005

90 % coverage at 2 ITNs per household90 % coverage at 2 ITNs per household

Protected more than 45 million people Protected more than 45 million people from malariafrom malaria

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Major Achievements: LLINsMajor Achievements: LLINs

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

2000 2001 2002 2003 2004 2005 2006 2007

Rapid scale up of ITNs in Ethiopia, 2000 - 2007Rapid scale up of ITNs in Ethiopia, 2000 - 2007

Net with 6-month treatments

Arrival of LLINs -Support from GFATM

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Status of ITNs distribution to Status of ITNs distribution to Regional States Regional States As of 15 August 2007As of 15 August 2007

RegionTotal number of

HHs at risk of malaria

Total Number of ITNs needed 2 ITNs/HHs

TotalDistributed

On procurement process

Total available coverage

(%)

Tigray 608,114 1,216,228 888,573 327,655 1,216,228 73

Afar 271,744 543,488 505,096 38,392 543,488 93

Amhara 2,980,168 5,960,335 5,192,398 767,937 5,960,335 87

Oromia 3,356,227 6,712,454 5,827,599 884,855 6,712,454 87

SNNPR 1,883,662 3,767,323 3,889,237 - 3,889,237 103

Somali 759,294 1,518,587 1,166,069 352,518 1,518,587 77

Gambella 61,750 123,500 197,900 - 197,900 160

B-gumuz 114,588 229,175 240,600 - 240,600 105

Harari 18,955 37,910 69,089 - 69,089 182

Dire dawa 35,000 70,000 137,314 - 137,314 196

Total 10,090,183 20,179,000

18,204,025 2,371,357 20,575,382 90.0

NB: This figure do not include the ones that are distributed through NGOs and the private sector

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ITNs utilization and ITNs utilization and knowledge issuesknowledge issues

ITNs utilization Study has been conducted ITNs utilization Study has been conducted in few parts of the countryin few parts of the country Number of HHs with children < 5years of age Number of HHs with children < 5years of age

reported used ITNs the previous night: reported used ITNs the previous night: East Hararge: 93.3%East Hararge: 93.3% Borena: 85.5%Borena: 85.5%

ITN cluster survey resultsITN cluster survey results H/Hs with 1 ITN hanging – 91%H/Hs with 1 ITN hanging – 91% Children sleeping under ITNs – 87%Children sleeping under ITNs – 87% Receiving health education – 82%Receiving health education – 82% Knowing malaria is dangerous to under 5’s – Knowing malaria is dangerous to under 5’s –

73%73%

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Achievements: IRSAchievements: IRS On average 800 tones of DDT 75% On average 800 tones of DDT 75%

procured and distributed every yearprocured and distributed every year Spray about 1 million unit structures Spray about 1 million unit structures

in more than 3000 localitiesin more than 3000 localities Protecting 1 million households and Protecting 1 million households and

5 million population5 million population Vector control and IRS Guidelines is Vector control and IRS Guidelines is

updatedupdated

20Source: data collected from Regional Health Bureaus, FMOH

Yearly Total and Malaria Out-Patients, EthiopiaYearly Total and Malaria Out-Patients, Ethiopia (July 2000 – June 2006)(July 2000 – June 2006)

21Source: data collected from Regional Health Bureaus, FMOH

Yearly Total Examined Cases and Malaria Positives, Yearly Total Examined Cases and Malaria Positives, EthiopiaEthiopia

(July 2000 – June 2006)(July 2000 – June 2006)

0

200

400

600

800

1,000

1,200

1,400

1,600

J uly 00 - J une 01J uly 01 - J une 02J uly 02 - J une 03J uly 03 - J une 04J uly 04 - J une 05J uly 05 - J une 06

Thousa

nds

years

num

ber

of ca

ses

0.0

10.0

20.0

30.0

40.0

50.0

60.0

% m

alar

ia c

ases

total examined % share of malaria

22Source: data collected from Regional Health Bureaus, FMOH

Yearly Total and Malaria Admissions, EthiopiaYearly Total and Malaria Admissions, Ethiopia (July 2000 – June 2006(July 2000 – June 2006))

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0

2000

4000

6000

8000

10000

12000

14000

16000

J uly 00 - J une01

J uly 01 - J une02

J uly 02 - J une03

J uly 03 - J une04

J uly 04 - J une05

J uly 05 - J une06

year

num

ber o

f dea

ths

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

% m

alar

ia d

eath

s

total death % malaria death

Source: data collected from Regional Health Bureaus, FMOH

Yearly Total and Malaria Deaths, Ethiopia Yearly Total and Malaria Deaths, Ethiopia (July 2000 – June 2006)(July 2000 – June 2006)

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0

500

1,000

1,500

2,000

2,500

July 00 - June 01 July 01 - June 02 July 02 - June 03 July 03 - June 04 July 04 - June 05 July 05 - June 06

year

num

ber of e

pid

em

ics

record

ed

total number of epidemics recorded

Source: data collected from Regional Health Bureaus, FMOH

Yearly Based Malaria Epidemics Recorded, Ethiopia Yearly Based Malaria Epidemics Recorded, Ethiopia (July 2000 – June 2006(July 2000 – June 2006))

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GFATM SupportGFATM Support

Malaria component received two round Malaria component received two round budget (Round 2 and Round 5)budget (Round 2 and Round 5)

Round 2: Five years budgetRound 2: Five years budget

US$ 76,875,211US$ 76,875,211

Round 5: Five years budgetRound 5: Five years budget

US$ 140,687,412US$ 140,687,412

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Areas supported by GFATM Areas supported by GFATM resourceresource

Supplies used for DiagnosisSupplies used for Diagnosis Microscopy, reagents Rapid diagnostic testMicroscopy, reagents Rapid diagnostic test

Drugs for malaria case managementDrugs for malaria case management Artemecinin based combination drugs Artemecinin based combination drugs

(CoArtem®) (CoArtem®)

Quinine Quinine

LLINsLLINs

Capacity building Capacity building

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GFATM Utilization statusGFATM Utilization status

RoundsRounds 5 Year 5 Year BudgetBudget UtilizedUtilized BalanceBalance

R 2R 2 76,875,21176,875,211 73,875,273,875,21111

3,000,03,000,00000

R 5R 5 140,687,41140,687,4122

60,000,060,000,00000

80,687,80,687,412412

TOTALTOTAL 217,562,62217,562,6233

133, 133, 875,211875,211

83,687,83,687,412412

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ChallengesChallenges

Sustaining the distribution and coverage of Sustaining the distribution and coverage of the ITNsthe ITNs

Supply of the costly anti malarial drugs and Supply of the costly anti malarial drugs and diagnostic materialsdiagnostic materials

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Future direction 2007-2010Future direction 2007-2010

Health sector development programHealth sector development program

Five years (2006 – 2010) strategic plan Five years (2006 – 2010) strategic plan producedproduced

Strategic directions:Strategic directions:

Further scale up the diagnosis and Further scale up the diagnosis and treatment activitiestreatment activities Ensure continuous supply of diagnostic Ensure continuous supply of diagnostic

materials and antimalarial drugs to the lowest materials and antimalarial drugs to the lowest level health facilitieslevel health facilities

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Future direction 2007-2010Future direction 2007-2010

Ensure 100% coverage of ITNsEnsure 100% coverage of ITNs Ensure ITNs replacement Ensure ITNs replacement

From 2008 onwards (to MDG date of 2015) an extra From 2008 onwards (to MDG date of 2015) an extra 50 million ITNs are needed to replace old nets to 50 million ITNs are needed to replace old nets to maintain >80% ITN coverage and utilization ratesmaintain >80% ITN coverage and utilization rates

Possible sources of fund/sustainability Possible sources of fund/sustainability GFATM 7 GFATM 7 Presidential Malaria Initiative (PMI) Presidential Malaria Initiative (PMI) Other donors ??Other donors ?? Local production of ITNs Local production of ITNs

Increase and sustain the ITNs Increase and sustain the ITNs utilization rateutilization rate

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Future direction 2007-2010Future direction 2007-2010

Scale up IRS to 60% and strengthen Scale up IRS to 60% and strengthen epidemic prevention and controlepidemic prevention and control

Monitoring and EvaluationMonitoring and Evaluation

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Program Budget 20072007 20082008 20092009 20102010

Total Required 131,787,894

103,138,154

125,827,092

182,947,666

Pledged (Govt, GFATM, PMI, WB and Other) 54,011,032

46,420,345

57,111,31360,048,00

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Gap 77,776,86256,717,809

68,715,779

122,899,659

Indicative Budget Requirement Indicative Budget Requirement and gap analysis (2007 – 2010)and gap analysis (2007 – 2010)