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Malaria Prevention and Control in Ethiopia

Malaria Prevention and Control in Ethiopia. Dr Afework Hailemariam, National Malaria Control Program, Ethiopia. Country Profile –Malaria Burden. 75% of the land malarious (altitude < 2000 m), >50 million(68%) of the population at risk, Malaria is the first cause of illness & death (2003/04)

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Malaria Prevention and Control in Ethiopia

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  1. Malaria Prevention and Control in Ethiopia Dr Afework Hailemariam, National Malaria Control Program, Ethiopia

  2. Country Profile –Malaria Burden • 75% of the land malarious (altitude < 2000 m), • >50 million(68%) of the population at risk, • Malaria is the first cause of illness & death (2003/04) • OPD 15.5%: 1st • Admissions 20.4%: 1st • Hospital Deaths 27.0%: 1st • Transmission season- Sept.- Dec., April- May, (seasonal & unstable) • Coincide with major harvesting season; aggravate economic loss, • Major epidemics occur every 5 - 8 years, focal epidemics are common,

  3. Impact of malaria control interventions: Trends in Malaria Cases, Admissions and Deaths

  4. Yearly Confirmed Malaria Cases, ETHIOPIA (1990 – 2006)REMARK: 2005 – 2006 data from Benishangul Gumuz & Dire Dawa not Included Source: health and health related indicators and data collected from Regional Health Bureaus, FMOH

  5. Yearly Malaria Out-Patients, ETHIOPIA (July 2000 – June 2006)REMARK: no data from Benishangul Gumuz and Dire Dawa for the year 2005 - 2006 Source: data collected from Regional Health Bureaus, FMOH

  6. Yearly Total Examined Cases and Malaria Positives, ETHIOPIA(July 2000 – June 2006)REMARK: no data from Benishangul Gumuz &Dire Dawa for the year 2005 - 2006 Source: data collected from Regional Health Bureaus, FMOH

  7. Yearly Malaria Admissions, ETHIOPIA (July 2000 – June 2006)REMARK: no data from Benishangul Gumuz and Dire Dawa for the year 2005 - 2006 Source: data collected from Regional Health Bureaus, FMOH

  8. Yearly Total Malaria Deaths, ETHIOPIA (1990 – 2006)REMARK: no data from Addis Ababa, Benishangul Gumuz &Dire Dawa for the year 2005 - 2006 Source: data collected from Regional Health Bureaus, FMOH

  9. Yearly Based Malaria Epidemics Recorded, ETHIOPIA (July 2000 – June 2006)REMARK: no data from Benishangul Gumuz &Dire Dawa for the year 2005 - 2006 Source: data collected from Regional Health Bureaus, FMOH

  10. Yearly Malaria Epidemics Recorded, ETHIOPIA(July 2000 – June 2006)REMARK: no data incorporated from Benishangul Gumuz and Dire Dawa Regional States for the year 2005 - 2006 Source: data collected from Regional Health Bureaus, FMOH

  11. Strategic Approaches 1) MAIN TECHNICAL ELEMENTS OF STRATEGIC APPROCHES: • Early diagnosis and effective treatment • Vector control • Insecticide treated materials • Residual house spray • Other vector control methods; Environmental Mx, Larviciding etc • Epidemic prevention and control 2) SUPPORTING STRATEGIES: • Human resource development • Operational research • Information, education and communication • Program monitoring and evaluation

  12. General Objective To reduce the overall burden of malaria (mortality and morbidity) by 50% by 2010.

  13. Specific Objectives • Achieve 100% access to effective and affordable treatment for malaria by the end of 2008 • Achieve 100% coverage of all households in ITNs targeted districts with at least two ITNs per household by August 2007,

  14. Specific Objectives contd…. • Achieve 60% coverage of villages targeted for Indoor Residual Spraying (IRS) the end of 2010 as compared to the 20-30% coverage in 2005, • Early detect and contain 80% of the malaria epidemics within two weeks from onset by 2010 as compared to 31% in 2005,

  15. Rapid Scale-up for Impact (SUFI)

  16. Case Management and Epidemics Activities

  17. Selected indicators on prompt and effective antimalarial treatment

  18. Selected Indicators on malaria epidemic prevention and control

  19. Annex II – Vector Control Activities

  20. Major Achievements: Vector Control/ITNs Vector Control: LLINs • 15.5 million LLINs have been Distributed to users • 5,108,168 nets have been procured and is on pipeline • 700,000 gap is secured or now under negotiation with partners (GF) • 88 % coverage at 2 ITNs per household

  21. ITN scaling-up in Ethiopia • Target 100% net coverage, 2007 • 2 ITNs per malaria affected household • Prioritize children & pregnant women Estimated total number of ITNs in Ethiopia 97% LLINs Arrival of LLINs Net with 6-month treatments

  22. Status of Procurement and Delivery of LLINs

  23. Yearly Unit Structures Targeted for Indoor Residual Spraying, ETHIOPIA (July 2000 – June 2006)REMARK: no data incorporated from Amahara, Benishangul Gumuz, and Dire Dawa Regional States for the year 2005 - 2006 Source: data collected from Regional Health Bureaus, FMOH

  24. Indicative Budget Requirement (2006 – 2010)

  25. GF ATM UNICEF WHO CIDA/CANADA The Carter Center USAID/PMI PSI PBS/The World Bank Japan/JICA DFID Other partners Major sources of fund in malaria prevention and control activities

  26. Data required for new malaria intervention introduction decisions • Efficacy and Effectiveness • Length of protection • Cost effectiveness compared to other interventions • Safety in different risk groups - <5s; pregnant women; breastfeeding; • High Reduction of occurrence of sever malaria • Potential for wide-spread use – all levels of health care system & community level, • Consumer acceptability • Formulation; • dosage regimen; taste, • Potential to delay resistance

  27. Example of decision-making • Policy change to ACTs is a good example • Efficacy study, • Validation of findings • Dissemination workshop • Recommendation • Guideline revision • Training of health workers • Resource mobilization and procurement • Implementation of the new policy

  28. Example of decision-making Anti-Malaria Drug Resistance in Ethiopia • Results from Isolated studies showed different levels of resistance to SP, • Less than 5% in Humera (1994) & Alamata (1998) • Treatment failure rate of 18% in Zuwai in 1998 Institute of Pathobiology, • Treatment failure rate of 30% in Zuwai in 2000 Institute of Pathobiology, • Not representative & lack of standardized protocol • Nationwide representative study not conducted in the period 1999 – 2002,

  29. Nationwide Assessment on the Efficacy of Sulfadoxine-Pyrimethamine A nationwide in-vivo Therapeutic Efficacy Study on Sulphadoxine-Pyrimethamine For the Treatment of Uncomplicated falciparum Malaria conducted in 11/14 sites, October – December 2003

  30. Anti-Malaria Drug Resistance Monitoring sites SP AL ND

  31. Mean treatment failure 35.9% (95%CI: 21.7 – 47.8) Sulfadoxine-Pyrimethamine Efficacy Study Findings & Treatment Policy Change 80% of the sites with TF rate of > 25%

  32. Treatment Failure Cut-offs & Recommended Actions >25% Change Period (reach consensus for change with in the shortest time possible) 6-15%: Alert Period (mechanism for the process of change) 16-24%:Action Period (activities to initiate change) <5%: Grace Period (active monitoring) 5 15 25

  33. Is There a Need to Change? • YES! • Preliminary findings of the nationwide therapeutic efficacy study results on sulfadoxine-pyrimethamine show treatment failure rates that warrant for change, • The need to use safe and effective anti-malaria drugs during malaria epidemics • Which drug (s)?

  34. National Workshop on Anti-Malarial Treatment Policy in Ethiopia – May 2004 • All stakeholders invited (about 90 participants) • Consensus reached on the Need to revise the diagnosis & treatment policy, • Rational to switch to more effective Artemisinine Based Combination Therapy (ACTs) than mono-therapy discussed, • Anti-malarial treatment options reviewed • Treatment of uncomplicated falciparum malaria • Artemether-Lumefantrine (highly recommended) • Artesunate + Amodiaquine (not recommended) • Artesunate + Sulfadoxine-Pyrimethamine (NR) • Artesunate + Mefloquine (needs investigation) • Non ACT option: SP + Amodiaquine (NR)

  35. Minimal criteria for selection of Anti-malarial drugs • Therapeutic efficacy – Clinical and parasitological cure • Safety in different risk groups - <5s; pregnant women; breastfeeding; • Potential for wide-spread use – all levels of health care system & community level, • Consumer acceptability- formulation; dosage regimen; taste, • Cost effectiveness • Potential to delay resistance

  36. Recommended Options for Ethiopia • Treatment of uncomplicated falciparum malaria • Artemether-Lumefantrine (highly recommended) • Artesunate + Amodiaquine (unlikely due to failure of AQ) • Artesunate + Sulfadoxine-Pyrimethamine (unlikely due to failure of SP) • Artesunate + Mefloquine (needs investigation) • Non ACT option: SP + Amodiaquine (unlikely due failure of both) • Treatment of vivax malaria (Chloroquine, Primaquine (radical cure) • Treatment of Sever & complicated malaria – Quinine • Chemoprophylaxis (Daily Proguanil + weekly chloqroquine) • Other issues to be considered • Need to identify safe drugs for the treatment of malaria during pregnancy, • Treatment of sever and complicated malaria in peripheral health facilities during malaria epidemics, • Chemo prophylactic drug for travellers (with easy dose regimen).

  37. 1. Artemether - Lumefantrine • AM-LUM is highly recommended: • Very past parasite elimination • Prompt reduction in fever • Effective gametocyte clearance • Effective in multi-drug resistant areas • Does not show any evidence of organ or system specific toxicity • Fixed dose combination treatment

  38. Efficacy Study Results of Artemether-Lumefantrine on P. falciparum Infections (Sep. – Dec. 2004)

  39. 1. Artemether – Lumefantrine… Course-of-therapy blister packs with simplified instructions for illiterate patients • 4 different packs: • 10-14 kg (1-2 yrs) • 15-24 kg (3-7 yrs) • 25-34 kg (8-10 ys) • 35+ kg (11+ ys)

  40. Together We Can Beat Malaria! Thank you

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