National Malaria Elimination

Program
Malaria Elimination
In Ethiopia
October 2021
ACIPH, Addis Ababa
Outline

▪ Overview: Malaria Epidemiology

▪ Malaria elimination roadmap

▪ Implementation Status

▪ Program challenges
Malaria Epidemiology in Ethiopia
▪ Ethiopia is a second Legend

populous country in etdtm200_ProjectRaster1_Rast1

Edge type
Africa Soft Edge
Elevation
▪ Malaria is among the top 2000 - 4455

communicable disease 150 - 2000

-164 - 150
▪ 3/4th of the area is
suitable for malaria
transmission;
▪ Mainly occurs up to 2,000
masl; rare case up to
2,400 masl.
▪ 53 % population is at risk
of malaria in this areas.

▪ Unstable and seasonal

pattern of transmission
▪ All age groups are
equally at risk
 Malaria Epidemiology in Ethiopia
▪ Parasites: P. falciparum and P. vivax are are the two
dominant parasite species, with proportions of about 70%
and 30%, respectively

▪ Vector distribution: An. arabiensisis is the only species from

the An. Gambaie complex known to be prevalent across
malaria-endemic areas in Ethiopia coupled with
An.Pharoensisis

▪ Positivity Rate ~ 24 % (HMIS,2020)

▪ parasite prevalence, Microscopic ~0.5% (MIS, 2015)

▪ Annual parasite Incidence, 26 (HMIS,2020)

Malaria Epidemiology in Ethiopia
 Background

▪ In the past decade, the Ethiopian government has

given high priority for malaria prevention and
control evidenced by scaling up key antimalarial
interventions.

▪ As a result of the unprecedented investment and

sustained high coverage of such interventions has
led to marked reduction of malaria morbidity and
mortality.
Major efforts at country level
▪ Since 2005, there were scaled up key
antimalarial interventions:
✓ All populations in malaria endemic areas covered with
LLINs;
✓ IRS fully covered the targeted areas;;
✓ Expanded diagnostic testing and
✓ Effective antimalarial treatment to peoples at risk;
▪ Health Extension program is introduced
▪ History of recurrent epidemics reversed;
▪ Reduction in morbidity and mortality recorded;
▪ Many woredas reporting <1 API, fulfil WHO’s criteria.
 ...major efforts

100,476,866
94,476,866
89,176,866
75,909,940
58,676,866
46,976,866
45,776,866

2012 2013 2014 2015 2016 2017 2018

Year
Achievement: LLINs distributed between 2012 and 2018
 ….major efforts
IRS Coverage

93.7 %

20 %

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Series1

Achievement: IRS coverage , Efficiency, 2008 - 2018

 ….major gains

Cases
4,068,764

1,698,499

962,087

Cases

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
 ….major gains

Death
2307

158 217

Death

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
 …major gains

Total case contribution Nigera Pv. Contribution, 2018 India

DRC
Uganda
Afgahanistan
Mozambique
Cote d'lvoire
Niger
1% 15% Pakistan
2% Burkina Faso
15%
2% Mali
3% Angola
5% Ethiopia
3% Tanzania
25%
India 6% 47%
3%
Ghana
3% 8% Papua New
Cameroun
Guinea
Rwanda
3% 8%
Benin
12% Indonesia
4% Malawi 11%
4% 5%
Kenya
Guinea
Others
Burundi
Others
Over all: The Shrinking malaria Map

13
 Global Commitment
Global Technical Strategy for Malaria 2016–2030

▪ To reduce malaria mortality rates to

At least 40% At least 75% At least 90%
zero in all countries by year 2030
▪ To reduce malaria case incidence to
zero in all countries by the year At least 40% At least 75% At least 90%
2030.
▪ To eliminate by 2030 in all
At least At least At least
countries with transmission in
10 countries 20 countries 35 countries
2015.
▪ To prevent re-establishment of Re- Re- Re-
malaria in all countries that are establishment establishment establishment
malaria-free prevented prevented prevented14
 Regional Commitment
▪ Need to align with the African Malaria Strategy (AMS) which targets
elimination of malaria from Africa by 2030;
▪ High level leadership alliance is committed/ALMA.

▪ To reduce malaria mortality rates to zero At least 40% At least 75% Zero malaria
in all countries by year 2030 death
▪ To reduce malaria case incidence to zero At least 40% At least 75% Zero malaria case
in all countries by the year 2030.
▪ To eliminate by 2030 in all countries with At least 8 At least 13 (8+5) In all 47 (13+34)
transmission in 2015. countries countries countries
Re-establishment Re-establishment Re-establishment
▪ To prevent re-establishment of malaria in prevented in prevented in prevented in
all countries that are malaria-free malaria-free malaria-free malaria-free
countries countries countries
Decision towards elimination

❑ Encouraged by the significant progress and

considering Global Technical Strategy (GTS) and African
Malaria Strategy (AMS).

❑ FMOH has clearly declared and committed to

eliminating malaria, targeting low transmission
districts in a given zone which will eventually be
scaled up to nationwide.
Decision towards elimination….

GTS AMS
National Malaria
Elimination
Roadmap

ACSM Guide

Malaria Diagnosis QA/

QC Manual

Malaria Vector Control

Manual

Malaria Surveillance
and M&E Manual
Programme Milestones

Vision
Malaria free Ethiopia

Goal
Eliminate malaria nationwide by 2030

Objectives
✓ Reduce malaria case incidence to zero by 2030;

✓ Reduce malaria mortality rate to zero by 2030;

✓ Prevent re-establishment of malaria in all malaria-free

districts.
Strategic approaches

1. Programme
Phasing &
Transitioning

5. Uptake of 2. Area
new Investing Stratification
technologies for Impact- &
and tools to make Interventions
Ethiopia Targeting
Malaria
Free

4. Stewardship 3. Community
& & Political
Accountability Engagement
 Malaria Elimination Strategies
In the context of the new NSP

No. of districts in 245

▪ Intensification of intervention
(High & - -
✓ Burden reduction
✓ Community parasite clearance moderate)

No. of districts in 565

▪ Elimination
(Low & 245 -
✓ Case & foci investigation
✓ Case based surveillances very low)

No. of districts in 236 236, 565 236, 565, 245

▪ Prevention of re-introduction
(Free = =
✓ Early detection of imported case
✓ Risk mitigation (vulnerability & receptivity) districts) 742 1046
1. Intensification
Strategic action:
▪ Focusing on improved quality, targeting and utilization of (tIRS and
tLSM) and universal coverage of all populations at risk with LLINs.

▪ Access to Dx and effective Rx in all health facilities including the

private

▪ Strengthen surveillance to assess progress and impact;

▪ Effective ACSM to optimize uptake of interventions and enhance

care seeking behaviour

▪ Strengthen programme management (human resource and supply)

▪ Enforcing political commitment and community engagement and

partnership
 2. Elimination
Strategic action:
▪ Case-based surveillance systems (including geo-coded case-based
mapping)

▪ Continued transmission blocking including radical treatment of P.

vivax since optimization

▪ Introduce more sensitive diagnostic tool (e.g. polymerase chain

reaction (PCR) and genotyping slide-banking capacity

▪ Cross-border/within country/collaboration to reduce the threat of re-

establishment of malaria from imported cases; and

▪ Community-based surveillance system using the HEWs and HDAs will

also be introduced
 Elimination…
Response: On hotspot
▪ In elimination setting where malaria transmission is
becoming patchy and clustered into hotspots;,
✓ tIRS, tLSM (if breeding site is permanent) in hotspots,

✓ Regular monitoring on the hotspots (using community-based

surveillance system)

✓ tMDA in the hotspots/ foci (mainly for P. falciparum) if

believed parasite reservoirs and low health seeking is a risk.

✓ SBCC at household and community level,

Day 1, 3 & 7 Surveillance System

Within 1 Day; At Local Within 3 Day; Case Within 7; Focus

Health Facility Investigation team Investigation team

All suspected malaria Focus investigation

cases Imported Local

Diagnosis with Case classification Active Residual Cleared

Microscopy or RDT focus Non up
active

Case notification-
Health worker reports Case investigation Response
Case to field team with
One day
4. Prevention of re-introduction

Strategic action:

Focus of surveillance activities:

▪ Early detection of imported malaria cases that pose a risk for
renewed transmission

▪ Vigilance to ensure that imported cases do not lead to re-

introduction of transmission;

▪ Maintain capacity for immediate notification, case investigation

and radical cure of all cases;

▪ Cross-border surveillance and collaboration

Implementation Status

❑ Baseline assessment
▪ Current health system capacity and gaps were assessed
based on six WHO Health System building blocks both at
office and HF level: interviewing with electronic
questioners using ODK

▪ Malaria prevalence assessment has been conducted in

20 selected woredas which have relatively high malaria
burden among elimination targeted ones

▪ Vector ecology survey has been conducted in 8 Sentinel

sites
 ….Implementation Status

❑ Advocacy and Social Mobilization

▪ Malaria elimination Launching at national level was conducted
on March 10/2017 in Adama

▪ Launching ceremony was conducted in all 6 regions

▪ Advocacy at zonal and woreda level was conducted in

targeted for ME

▪ Central level 4messages each on radio &TV/EBC

▪ Regional level spot message transmitted using local media with

regional local language
 ….Implementation Status
❑ Program Management
▪ Manuals and Guidelines have been developed, printed
and distributed to region by 46,000 copies

▪ Development of manuals and job aids

❑ Capacity building
▪ Orientational training and HR

▪ Laboratory training

❑ Case management & Diagnostic Capacity building

▪ Establishing 6 malaria PCR at regional level
 ….Implementation Status
▪ 500 microscopies were distributed

▪ Ensuring anti-malaria drugs and Diagnostic equipment including

radical cure primaquine

❑ Surveillance
▪ Adapting DHIS-2, PHEM and e-CHIS tools to NMCAEP.

❑ Human Resource Capacity Building

▪ Establishment of anti-malaria school club

▪ TAs both for Entomology and Epidemiology have been

deployed at central, Regional and zonal level
 Shrinking the
malaria Map

Selected Districts = 239

High stratum = 1
Moderate = 82
Low = 153
Free = 4
Selected Districts = 240
High Stratum = 0
Moderate = 4
Low = 220
Free = 16

Selected Districts = 240

High Stratum = 0
Moderate = 45
Low = 166
Free = 31 Selected Districts = 240
High Stratum = 0
Selected Districts = 240
Moderate = 36
High Stratum = 0
Low = 184
Moderate = 58
Free = 20
Low = 166
Free = 20
In general

258,890 254,065

159730 164475

115198

2008 2009 2010 2011 2012

Phase Two: Case and foci Invest.

# Basic trainings on case and foci investigation held in six regions, 12

zones, 239 woredas and 1,317 health facilities,

# Cascading training provided by Oromia, Amhara, Diredawa & Harari

regions

# Intensive sensitization and awareness creation at all levels

# Production and distribution of printed materials: SOPs, Protocols,

Manuals, Guidelines and Registration and reporting formats
Active Foci Investigation

Plan Achivement

1305
421 405 434 45 0 0 0
2163
734 425 434 570
0 0 0

Oromia SNNPR Amhara Sidama Diredewa Harari Tigray Total

Index cases investigation

Plan Achivement 16867

4979 13,409
4000 5023

2355
4368 4040 3323
1484 315 195 0
187
7
Oromia SNNPR Amhara Sidama Diredewa Harari Tigray Total
Financing elimination program
Category 2021 2022 2023 2024 2025 Total

A. Total national
112,317,588 113,813,342 82,767,048 113,636,620 121,856,796 544,391,394
strategic plan budget

B. Current and
expected domestic 32,658,912 32,581,665 32,588,387 36,419,265 36,404,042 170,652,270
resources

C. Current and
expected external 57,012,982 61,270,389 36,650,317 18,205,084 18,440,656 191,579,428
resources

D. Total current and

planned resources 89,671,894 93,852,053 69,238,705 54,624,348 54,844,698 362,231,698
(B+C)

E. Financial gap (A-D) 22,645,694 19,961,289 13,528,344 59,012,272 67,012,099 182,159,696

Program Challenge
# Climatic anomalies, which
facilitated surge of the disease in
2019/2020

# The COVID-19 pandemic

# Security issues & IDP in various

parts of the country,

# Emergence of an invasive vector,

Anopheles Stephensi