Baseline malaria prevalence at the targeted pre-elimination districts in Ethiopia

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 > 37.5^oc) 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.

Safety and efficacy of artemether-lumefantrine in the treatment of uncomplicated falciparum malaria in Ethiopia

OBJECTIVE

To document baseline data on the efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated falciparum malaria in Ethiopia.

DESIGN

Patients diagnosed for P. falciparum, who were treated with six doses of artemether-lumefantrine over three days, were followed for 28 days and treatment outcomes classified based on the WHO (2003) protocol.

SETTING

Four health facilities located in malarious areas in two regions: Alamata and Humera hospitals in Tigray region and Assendabo and Nazareth in Oromia region.

SUBJECTS

Patients with body weight of more than 10 kgs, excluding pregnant women, who or their guardians consented to participate in the study after fulfilling the inclusion criteria were enrolled in the study for a follow-up period of 28 days.

MAIN OUTCOME MEASURES

Proportion of treatment success and adverse drug effects that required discontinuation of treatment and/or follow-up.

RESULTS

A total of 213 patients who fulfilled the enrolment criteria completed the 28 days follow-up after treatment with artemether-lumefantrine. A treatment success rate of 99.1% (95% confidence interval [CI] 96.9, 99.8) and no adverse effects or complaints related to the drug that required discontinuation of treatment or withdrawal from follow-up was reported. Treatment success was not achieved in 213 (0.9%) subjects for whom fever and peripheral parasitaemia was demonstrated on day 21 and 28. The day 21 and day 28 blood samples of the treatment failure cases were not PCR corrected.

CONCLUSION

The artemisinin based combination drug artemether-lumefantrine has shown very high (99.1%) clinical and parasitological cure for the treatment of uncomplicated falciparum malaria with no reports of adverse reaction that required withdrawal of treatment or discontinuation of follow-up. In the presence of the low efficacy of sulfadoxine-pyrimethamine, chloroquine and amodiaquine, the use of artemether-lumefantrine for the treatment of uncomplicated falciparum malaria is the best choice for Ethiopia.

Efficacy of sulfadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria in Ethiopia

OBJECTIVE

To assess the status of the therapeutic efficacy of sulfadoxine-pyrimethamine for the treatment of uncomplicated falciparum malaria to enable evidence based policy decisions.

DESIGN

The study used the new WHO (2003) protocol for the assessment of the therapeutic efficacy of anti-malarial drugs.

SETTING

Eleven health facilities located in malarious areas with seasonal transmission.

SUBJECTS

Patients aged six months and above who presented to the health facilities for febrile illness and for whom consent was obtained to participate in the study after fulfilling the inclusion criteria were enrolled in the study.

MAIN OUTCOME MEASURES

Proportion of treatment failures.

RESULTS

In eleven (90.9%) of the sites, where adequate sample was collected, a total of 598 subjects were enrolled and 487 (81.4%) completed the follow-up. A mean treatment failure rate of 35.9% (95% confidence interval [CI] 31.8, 40.3) on the 14 days follow-up and 71.7% (95% CI 67.5, 75.9) on the 28-days follow-up was recorded (not PCR corrected). The mean clinical failure on the 14-days follow-up was 20.9% (95% CI 17.5, 24.7) and 70% (n=10) sites had aggregated clinical failure rates higher than 15%, while in 80% (n=10) sites the total treatment failure exceeded 25%. There was no significant difference in treatment failure rates in areas with malaria transmission duration of six months and above as compared to areas with below six months of transmission (odds ratio [OR] = 0.9, 95% CI 0.43,1.83 p = 0.75). The difference in mean treatment failure between the <5 and > or =15 years of age was not significant (OR 0.8, 95% CI 0.39,1.67 P = 0.54).

CONCLUSION

The level of treatment failure detected is much higher than the WHO recommended tolerable levels. The findings, therefore, strongly indicate the need for an immediate review of the existing national anti-malarial treatment guideline.

Timing of the introduction into Ethiopia of subcluster C' of HIV type 1 subtype C

Viruses circulating in Ethiopia during the 1990s cluster with main subtype C, but a significant subcluster, C', was noted in multiple analyses. This subcluster of subtype C(C') was in a fifty-fifty equilibrium with the main subtype C (Abebe et al., AIDS Res Hum Retroviruses 2000;16:1909-1914). To analyze genetic diversification within the subcluster of HIV-1 subtype C designated C' in the course of the epidemic in Ethiopia, we analyzed 165 env gp120 V3 sequences obtained between 1988 and 1999. We observed a highly significant positive correlation between sampling years of individual sequences and their synonymous distances to the reconstructed common ancestor of the HIV-1 subtype C' subcluster. The extrapolation of the regression line of synonymous distances back to the date when no synonymous heterogeneity was present among the Ethiopian HIV-1 C' population allowed us to estimate 1982 (95% CI, 1980-1983) as the year of the onset of HIV-1 C' genetic diversification and expansion in Ethiopia. These results are in agreement with retrospective epidemiological and serological data, which demonstrated the absence of an HIV-1 epidemic in the Ethiopian population before the 1980s.

Identification of a genetic subcluster of HIV type 1 subtype C (C') widespread in Ethiopia

Others and we have previously shown that subtype C is the predominant HIV-1 subtype and the major cause of AIDS in Ethiopia. The present study shows that subtype C in Ethiopia has a genetic subcluster, designated C', has not increased in frequency, or spread geographically, over the period 1988 (%C' = 23/53) to 1996-1997 (%C' = 26/50). There is no association of the HIV-1 subtype C or subcluster C' with geographic location, time of sample collection, or risk group in Ethiopia. Of 105 randomly collected samples representing 7 different towns in Ethiopia, all but 2 (1 subtype A from Addis Ababa, 1997 and 1 subtype D from Dessie, 1996) belong to subtype C.

[Blood transfusion in Ethiopia]

Nearly 30,000 bags of blood are collected per year in Ethiopia for a population of 56 million people. Eighty percent of this volume is obtained from family donors at the ten blood banks run by the National Transfusion Blood Service (NTBS) under the auspices of the International Red Cross. The remaining 20% are collected in hospital laboratories not affiliated with the NTBS but where blood bank procedures are used including the ability to screen for HIV contamination. Transfusion is thus a safe procedure in the major towns of Ethiopia. Screening for hepatitis B is performed only on blood to be administered to children and foreigners.