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S40249-020-00773-5.Pdf Esayas et al. Infect Dis Poverty (2020) 9:160 https://doi.org/10.1186/s40249-020-00773-5 RESEARCH ARTICLE Open Access Malaria epidemiology and stratifcation of incidence in the malaria elimination setting in Harari Region, Eastern Ethiopia Endashaw Esayas1,2* , Asefa Tufa1, Fekadu Massebo3, Abdulhamid Ahemed1, Ibssa Ibrahim1, Dereje Dillu4, Eyuel Asemahegn Bogale2, Solomon Yared5 and Kebede Deribe6,7 Abstract Background: Ethiopia has shown notable progress in reducing the burden of malaria over the past two decades. Because of this progress, the country has shifted eforts from control to elimination of malaria. This study was con- ducted to analyse the malaria epidemiology and stratifcation of incidence in the malaria elimination setting in eastern Ethiopia. Methods: A retrospective study was conducted to analyse the epidemiology of malaria by reviewing the district health ofce data from 2013 to 2019 in Harari Region. In addition, three years of sub-district level malaria data were used to stratify the malaria transmission intensity. Malaria interventions (Long-lasting insecticidal nets [LLIN] and indoor residual spraying [IRS]) employed were reviewed to analyse the intervention coverage at the Regional level. Descriptive statistics were used to show the malaria transmission in terms of years, season and species of the malaria parasite. Incidence rate per 1000 population and death rate per 1 000 000 population at risk were computed using the total population of each year. Results: In the Harari Region, malaria incidence showed a more pronounced declining trend from 2017 to 2019. Plasmodium falciparum, P. vivax and mixed infections accounted for 69.2%, 30.6% and 0.2% of the cases, respectively. There was an increment in malaria intervention coverage and improved malaria diagnosis. In the year 2019 the cover- age of LLIN and IRS in the Region were 93.4% and 85.1% respectively. The annual malaria incidence rate dropped from 42.9 cases per 1000 population in 2013 to 6.7 cases per 1000 population in 2019. Malaria-related deaths decreased from 4.7 deaths per 1 000 000 people annually in 2013 to zero, and there have been no deaths reported since 2015. The malaria risk appears to be heterogeneous and varies between districts. A higher number of malaria cases were recorded in Erer and Jenella districts, which constitute 62% of the cases in the Region. According to the sub-district level malaria stratifcation, there was shrinkage in the malaria transmission map and about 70% of the sub-districts have achieved elimination targets. Conclusions: In the Harari Region, malaria morbidity and mortality have been signifcantly declined. Thus, if this achievement is sustained and scaling-up of the existing malaria prevention and control strategies by focusing on those populations living in the higher malaria transmission districts and sub-districts, planning of malaria elimination from the study area might be feasible. *Correspondence: [email protected] 2 Malaria and Neglected Tropical Diseases Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia Full list of author information is available at the end of the article © The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Esayas et al. Infect Dis Poverty (2020) 9:160 Page 2 of 12 Keywords: Malaria elimination, Epidemiology, Incidence, Harari region, Ethiopia, Interventions, Sub-district, Stratifcation Background to further reduce the risk of infection [13–15]. Tus, Malaria poses threats to the public health of the world, analyzing transmission intensity and the interventions with a particular burden of disease in sub-Saharan employed each year is important for the expansion of Africa [1]. Globally, in 2018 there were an estimated intervention strategies or to design new ones to tackle 228 million new malaria cases and, of these, about the disease. Harari Region was selected by the National 405 000 malaria-related deaths. Deaths are most com- Malaria Elimination Program for the possible malaria mon in children under the age of fve years in sub-Saha- elimination and as such, a malaria elimination strategy ran Africa. Te World Health Organization (WHO) was launched and is under implementation since 2017. African Region bearing the highest burden of malaria However, the comprehensive evaluation of changes in cases (93%) and deaths (94%) [2]. regional malaria cases and progress made in malaria In Ethiopia, the burden of malaria continues to cause control interventions and the malaria epidemiology a substantial number of morbidity and mortality which are not studied in the Region. Terefore, this study was accounts for most outpatient visits. Malaria has been aimed at analyzing the epidemiology of malaria and one of the main causes of hospitalization and deaths the coverage of interventions employed in the Harari in the country [3, 4]. About 60% of the population are Region. Furthermore, the present study stratifes the living in the malaria risky areas, mainly areas that lie malaria transmission intensity at the sub-district levels, below 2000 m above sea level [4, 5]. However, several which may contribute to the evidence-based decision pockets with micro-epidemiological conditions sup- for malaria control and elimination strategies. porting malaria transmission occur in areas above this altitude [6, 7]. Plasmodium falciparum and P. vivax are Methods the dominant parasites responsible for the majority of Study area description malaria cases in Ethiopia. Te contribution of other Tis study was carried out in Harari Regional State, one Plasmodium species in the country is negligible [5, 8]. of the Regional States of Federal Democratic Repub- Since 2000 there has been a substantial increase in lic of Ethiopia, located in the eastern part of the coun- investment to support malaria interventions in Africa, try 515 km from the national capital Addis Ababa. Te including Ethiopia. Due to this commitment over the region is surrounded by Oromia Regional State (Fig. 1). past two decades, a signifcant reduction of malaria has Te Region covers a total area of 342.2 square km with been registered in Ethiopia. Tis improvement could an estimated total population of 270 000. Te Region is be attributed to improved coverage of key antimalarial located within 9° 11′ 49″–9° 24′42″ N Latitude and 42° interventions, including, distribution of long-lasting 03′ 30″–42° 16′ 24″ E Longitude and the altitude of the insecticidal nets (LLIN) through mass campaigns tar- Region ranges between 1552 and 1957 m above sea level. geting the entire population at risk, indoor residual Te mean annual temperature of the Region ranges from spraying (IRS) in designated epidemic-prone areas, 18 to 21 °C and the mean annual rainfall ranges from 687 and expanded diagnostic testing and efective antima- to 775 mm. Te Region is divided into three rural dis- larial treatment to people at risk [5, 8–10]. Based on tricts (Dire Teyara, Sof and Erer districts) and 6 urban this progress, Ethiopia has recently planned to achieve districts within Harar Town Administration (Abadir, nationwide malaria elimination by 2030 by starting Aboker, Amir Nur, Jenella, Hakim and Shenkor districts). sub-national elimination in districts with low malaria Tese districts are administratively further sub-divided transmission [8]. into 36 sub-districts (kebeles). Since 2016, the poten- Evaluation of changes in malaria epidemiology and tial primary health service coverage in the Region is malaria control interventions are used for public estimated to be close to 100%. In Harari Regional State health surveillance and monitoring, forecasting, pro- there are six hospitals (two public, two military, a private gram evaluation, policy analysis and investigation of and a non-governmental), one Regional laboratory and potentially causal relationships between risk factors research centre, eight health centres, 32 health posts and and outcomes [3, 11, 12]. Moreover, identifying loca- 40 private clinics [16]. In addition to the regional people, tions and populations with a higher risk of malaria the health facilities in the region are giving services for would help appropriate planning and implementation the eastern part of Ethiopia. For instance, the Regional of targeted intervention strategies against the disease laboratory is serving as a testing centre for early infant Esayas et al. Infect Dis Poverty (2020) 9:160 Page 3 of 12 Fig. 1 Location of Harari Region in the map of Ethiopia and study sub-districts (kebeles) diagnosis for health
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