1. 1 Malaria Prevention and Control in Ethiopia Dr Daddi Jima National Malaria Control Program, Ethiopia

2. 2 History of Malaria control organization 1959 - Malaria Eradication Service established 1959 - Malaria Eradication Service established One year after major malaria epidemic One year after major malaria epidemic 1971 - Vertical Malaria Control Program 1971 - Vertical Malaria Control Program 1993 – Malaria control was integrated into general health system and decentralized 1993 – Malaria control was integrated into general health system and decentralized

3. 3 Malaria Epidemiology 75% of the land ( areas below 2000 m above sea level) is malarious 75% of the land ( areas below 2000 m above sea level) is malarious Fertile low land areas Fertile low land areas Suitable for agriculture Suitable for agriculture >50 million (68%) of the population live in these areas and at risk of malaria >50 million (68%) of the population live in these areas and at risk of malaria Transmission is unstable and seasonal Transmission is unstable and seasonal September to December and April to May September to December and April to May Coincide with major planting and harvesting season for farmers - aggravate economic loss Coincide with major planting and harvesting season for farmers - aggravate economic loss

4. 4 Malaria Epidemiology Major epidemics occur every 5 - 8 years, but focal epidemics are happen every year, Major epidemics occur every 5 - 8 years, but focal epidemics are happen every year, Two parasite species Two parasite species Plasmodium falciparum (60%) Plasmodium falciparum (60%) P. vivax (40%) P. vivax (40%) Main malaria vector Main malaria vector Anopheles arabiansis Anopheles arabiansis Anopheles pharoensis Anopheles pharoensis

5. 5 Malaria Burden Malaria is a major public health problem in Ethiopia Malaria is a major public health problem in Ethiopia Every year it is the leading cause of out patient consultations, admissions and death Every year it is the leading cause of out patient consultations, admissions and death

6. 6 Malaria Burden

7. 7

8. 8 The goal of malaria prevention and control in Ethiopia To contribute to MDG 6 target 8 by reducing the overall burden of malaria by 50% by the year 2010 To contribute to MDG 6 target 8 by reducing the overall burden of malaria by 50% by the year 2010AND To contribute to the reduction of child mortality (MDG 4) and improvement of maternal health (MDG 5) To contribute to the reduction of child mortality (MDG 4) and improvement of maternal health (MDG 5)

9. 9 Malaria prevention and control strategies 1) Main strategies : Early diagnosis and effective treatment Early diagnosis and effective treatment Vector control Vector control Insecticide treated nets Insecticide treated nets Indoor Residual Spray Indoor Residual Spray Epidemic prevention and control Epidemic prevention and control 2)Cross cutting Strategies: Human resource development Human resource development Operational research Operational research Information, education and communication Information, education and communication Program monitoring and evaluation Program monitoring and evaluation

10. 10 Government policy towards malaria control in Ethiopia: Priority to communicable diseases Priority to communicable diseases Free diagnosis (especially at lower health facilities level) Free diagnosis (especially at lower health facilities level) Free anti-malarial drugs Free anti-malarial drugs Free distribution of ITNs to all Free distribution of ITNs to all Free indoor residual spraying of houses Free indoor residual spraying of houses

11. 11 Malaria Diagnosis & Treatment Diagnosis: Diagnosis: Clinical, Rapid diagnostic tests and Microscopy Clinical, Rapid diagnostic tests and Microscopy Treatment Treatment 1 st line - Artemether-Lumefantrine (Coartem®) for P.falciparum and CQ for P.vivax 1 st line - Artemether-Lumefantrine (Coartem®) for P.falciparum and CQ for P.vivax Quinine for pregnant women & children <5kg Quinine for pregnant women & children <5kg 2 nd line treatment – quinine tablets 2 nd line treatment – quinine tablets Severe malaria – quinine injection Severe malaria – quinine injection

12. 12 Indoor Residual Spraying Indoor residual spraying has been implemented in Ethiopia for more than 4 decades. Indoor residual spraying has been implemented in Ethiopia for more than 4 decades. The insecticide used is DDT 75% The insecticide used is DDT 75% Every year 20% – 30% of sprayable localities covered Every year 20% – 30% of sprayable localities covered

13. 13 Distribution started with ordinary nets since 1998 Distribution started with ordinary nets since 1998 Coverage and re-impregnation rate was low Coverage and re-impregnation rate was low LLINs introduced in 2005 LLINs introduced in 2005 Rapid scale- up was carried out Rapid scale- up was carried out GFATM and other donors GFATM and other donors 2 nets per household 2 nets per household 20 mln nets needed to cover all 20 mln nets needed to cover all Use of insecticide treated nets

14. 14 Major Achievements: Diagnosis and Treatment Target: Universal coverage of fever treatment within 24 hours of onset in 2008 Target: Universal coverage of fever treatment within 24 hours of onset in 2008 Diagnosis and treatment guideline revised Diagnosis and treatment guideline revised RDT procurement and distribution (>2 million tests) RDT procurement and distribution (>2 million tests) Coartem procured and distributed (> 6 million doses every year for the last 2 years) Coartem procured and distributed (> 6 million doses every year for the last 2 years) Opportunity Opportunity Accelerated expansion of primary health service coverage - universal health service coverage by 2008 Accelerated expansion of primary health service coverage - universal health service coverage by 2008 Health extension program Health extension program Better financial input: GFATM, PMI Better financial input: GFATM, PMI

15. 15 Major Achievements: LLINs Target: to cover all households in malarious areas with at lease 2 nets per household (20 million nets) in 2007 and to protect more than 50 million people. Target: to cover all households in malarious areas with at lease 2 nets per household (20 million nets) in 2007 and to protect more than 50 million people. 18.2 million LLINs have been distributed to beneficiaries since 2005 18.2 million LLINs have been distributed to beneficiaries since 2005 90 % coverage at 2 ITNs per household 90 % coverage at 2 ITNs per household Protected more than 45 million people from malaria Protected more than 45 million people from malaria

16. 16 Major Achievements: LLINs Rapid scale up of ITNs in Ethiopia, 2000 - 2007 Net with 6-month treatments Arrival of LLINs - Support from GFATM

17. 17 Status of ITNs distribution to Regional States As of 15 August 2007 Region Total number of HHs at risk of malaria Total Number of ITNs needed 2 ITNs/HHs Total Distributed 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 - 103 Somali 759,294 1,518,587 1,166,069 352,518 1,518,587 77 Gambella 61,750 123,500 197,900 - 160 B-gumuz 114,588 229,175 240,600 - 105 Harari 18,955 37,910 69,089 - 182 Dire dawa 35,000 70,000 137,314 - 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

18. 18 ITNs utilization and knowledge issues ITNs utilization Study has been conducted in few parts of the country ITNs utilization Study has been conducted in few parts of the country Number of HHs with children < 5years of age reported used ITNs the previous night: Number of HHs with children < 5years of age reported used ITNs the previous night: East Hararge: 93.3% East Hararge: 93.3% Borena: 85.5% Borena: 85.5% ITN cluster survey results ITN 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 – 73% Knowing malaria is dangerous to under 5’s – 73%

19. 19 Achievements: IRS On average 800 tones of DDT 75% procured and distributed every year On average 800 tones of DDT 75% procured and distributed every year Spray about 1 million unit structures in more than 3000 localities Spray about 1 million unit structures in more than 3000 localities Protecting 1 million households and 5 million population Protecting 1 million households and 5 million population Vector control and IRS Guidelines is updated Vector control and IRS Guidelines is updated

20. 20 Source : data collected from Regional Health Bureaus, FMOH Yearly Total and Malaria Out-Patients, Ethiopia (July 2000 – June 2006)

21. 21 Source : data collected from Regional Health Bureaus, FMOH Yearly Total Examined Cases and Malaria Positives, Ethiopia (July 2000 – June 2006)

22. 22 Source : data collected from Regional Health Bureaus, FMOH Yearly Total and Malaria Admissions, Ethiopia (July 2000 – June 2006 )

23. 23 Source : data collected from Regional Health Bureaus, FMOH Yearly Total and Malaria Deaths, Ethiopia (July 2000 – June 2006)

24. 24 Source : data collected from Regional Health Bureaus, FMOH Yearly Based Malaria Epidemics Recorded, Ethiopia (July 2000 – June 2006 )

25. 25 GFATM Support Malaria component received two round budget (Round 2 and Round 5) Malaria component received two round budget (Round 2 and Round 5) Round 2: Five years budget Round 2: Five years budget US$ 76,875,211 US$ 76,875,211 Round 5: Five years budget Round 5: Five years budget US$ 140,687,412 US$ 140,687,412

26. 26 Areas supported by GFATM resource Supplies used for Diagnosis Supplies used for Diagnosis Microscopy, reagents Rapid diagnostic test Microscopy, reagents Rapid diagnostic test Drugs for malaria case management Drugs for malaria case management Artemecinin based combination drugs (CoArtem®) Artemecinin based combination drugs (CoArtem®) Quinine Quinine LLINs LLINs Capacity building Capacity building

27. 27 GFATM Utilization status Rounds 5 Year Budget UtilizedBalance R 2 76,875,21173,875,2113,000,000 R 5 140,687,41260,000,00080,687,412 TOTAL217,562,623 133, 875,211 83,687,412

28. 28 Challenges Sustaining the distribution and coverage of the ITNs Sustaining the distribution and coverage of the ITNs Supply of the costly anti malarial drugs and diagnostic materials Supply of the costly anti malarial drugs and diagnostic materials

29. 29 Future direction 2007-2010 Health sector development program Health sector development program Five years (2006 – 2010) strategic plan produced Five years (2006 – 2010) strategic plan produced Strategic directions: Strategic directions: Further scale up the diagnosis and treatment activities Further scale up the diagnosis and treatment activities Ensure continuous supply of diagnostic materials and antimalarial drugs to the lowest level health facilities Ensure continuous supply of diagnostic materials and antimalarial drugs to the lowest level health facilities

30. 30 Future direction 2007-2010 Ensure 100% coverage of ITNs Ensure 100% coverage of ITNs Ensure ITNs replacement Ensure ITNs replacement From 2008 onwards (to MDG date of 2015) an extra 50 million ITNs are needed to replace old nets to maintain >80% ITN coverage and utilization rates From 2008 onwards (to MDG date of 2015) an extra 50 million ITNs are needed to replace old nets to maintain >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 utilization rate Increase and sustain the ITNs utilization rate

31. 31 Future direction 2007-2010 Scale up IRS to 60% and strengthen epidemic prevention and control Scale up IRS to 60% and strengthen epidemic prevention and control Monitoring and Evaluation Monitoring and Evaluation

32. 32 Program Budget2007200820092010 Total Required 131,787,894 103,138,1 54 125,827,09 2 182,947, 666 Pledged (Govt, GFATM, PMI, WB and Other) 54,011,032 46,420,34 5 57,111,313 60,048,0 07 Gap 77,776,862 56,717,80 9 68,715,779 122,899, 659 Indicative Budget Requirement and gap analysis (2007 – 2010)