MEKELLE UNIVERSITY AND ADDIS CONTINENTAL

INSTITUTE OF PUBLIC HEALTH JOINT MPH PROGRAM

PREVALENCE OF URBAN MALARIA CASE IN ADWA TOWN,

Central zone of Tigray.

BY

DAGNEW HAGEZOM
E-mail dagnewhagezom@yahoo.com
Cell phone 0914752172
Department of public Health

Advisor Prof. YEMANE BERHANE (MD, MPH, Ph.D.)

Co Advisor Solomon Gebremariam (MD,MSC)

June 16/2010
Mekelle, Ethiopia
Acknowledgement
I would like to thank Prof. Yemane Berhane for devoting all his time & energy in correcting and
shaping both my proposal and final paper. I am grateful to public Health Department of Mekelle
University especially to my contact person Dr.solomon G/mariam for assisting with devotion and
concern, in each and every step of the proposal and research paper. I would also like to extend
my heartiest appreciation to Ato Abebe G/selassie Adwa wereda health office head ,Ato Goitom
Gigar Adwa Hospital CEO,Ato Haile G/selassie and all laboratory technicians in both the health
facilities for their material, manpower & moral support during data collection.

I.
Table of contents

Acknowledgement..........................................................................................................................I
List of tables....................................................................................................................................II
List of Figures................................................................................................................................III
List of Acronyms...........................................................................................................................III
Abstract .IV
1) Introduction..........................................................................................................................1
2) Literature Review.................................................................................................................3
2.1 Urban malaria in Africa...........................................................................................3
2.2 Malaria morbidity and mortality..............................................................................3
2.3 prevention and control.............................................................................................4
2.4 prevalence of malaria...............................................................................................5
2.5 Age dependence of malaria......5
2.6 Climatic and geographical parameters and malaria.................................................6
2.7 Mosquito net use and malaria..................................................................................6
3) Objective............................................................................................................................. 7
3.1 General Objective....................................................................................................7
3.2 Specific Objectives .................................................................................................7
4) Materials and Methods.......................................................................................... .7
4.1. study design...........................................................................................................7
4.2. Study area .............................7
4.3. Study Population...................................................................................................7
4.3.1. Inclusion criteria.......................................................................................7
4.4. Sample size determination...................................................................................7
4.4.1 Quantitative...........................................................................................7
4.4.2 Qualitative........8
4.5. Data collection procedures....................................................................................8
4.5.1 key informants interview........8
4.6. Quality control......................................................................................................8
4.7. Data Analysis procedures.....................................................................................8
4.7.1 Quantitative......8
4.7.2 Qualitative............8
4.6. Ethical Consideration............................................................................................8
5) Results..................................................................................................................................9
5.1 Prevalence of malaria in the health center9
5.2 Prevalence of malaria in the hospital..9
5.3 Prevalence of malaria in the town..10
5.4 Major findings from the qualitative data(FGD).13
5.4.1 Perception about the magnitude of malaria and its impacts..13
5.4.2 Major methods of prevention and control of malaria13
6) Discussion..14
7) Conclusions and Recommendations..................................................................................15
7.1 Conclusion..15
7.2 Recommendation....15
II.
 References............................................................................................................................16
Annex 1: consent form.18
Annex 1: Structural interview for health administrators..........................................................18
Annex 2: Laboratory results reporting format.........................................................................18

List of tables

Table.1 prevalence of malaria from Adwa Health center 2008/09 Data 9

Table.2 prevalence of malaria from Adwa Hospital 2008/09 Data ..10
Table.3 prevalence of malaria in Adwa Town a combination of the two health facilities
2008/09 Data...10

List of Figures/Charts

Chart1: bar graph of prevalence of malaria cases in the town 2008/09.11

Chart 2: Age distribution of malaria cases in Adwa town 2008/09.......12
Chart 3: malaria cases by sex in Adwa town 2008/09...13

List of Acronyms

ACT: Artemesinin Combination Therapy

DDT: Dichlorodiphenyltrichloroethane
DHS: Demographic and Health Survey
IEC: Information Education Communication
IRS: Indoor Residual Spraying
ITNs: Insecticide Treated bed Nets
CEO: chief executive officer
MOH: Ministry Of Health
PF: Plasmodium falciparum
PV: Plasmodium vivax
SP: Sulphadoxine-Pyrimethamine
WHO: World Health Organization

III.
Abstract
Background: It is estimate that 200 million people (24.6% of the total African population)
currently live in urban settings where they are at risk of contracting the disease. Importantly, the
estimated total surface area covered by these urban settings is only approximately 1.11.6% of
the total African surface. Considering different plausible scenarios, I estimate an annual
incidence of 7001000 cases of clinical malaria attacks among urban dwellers in Adwa town.
These figures translate to 57.13% of the estimated global annual disease incidence. Mitigation
of the current burden of malaria in Adwa town settings, in turn, is a necessity for stimulating
environmentally and socially sustainable development.

Objective: The purpose of the study was to estimate malaria prevalence and its influencing
factories in the Adwa town.
Methods: The study design was a retrospective study based on the health institution records
from register books and data from key informants. And Data were collected with non random
sampling from the health center and hospital which were febrile patients and malaria cases in
2008/09. Subjective ideas were also collected using Key informants' interviews and literatures.
Finally the data were analyzed using computer desk top that is excel and simple calculator
Results: The study subjects had the following results, all malaria cases from all clients (5.10%),
malaria cases from all febrile patients (13.02%), plasmodium faciparium from all malaria cases
(89.53%), plasmodium vivax from all malaria cases (10.20%), and mixed from all malaria cases
(0.28 %), and malaria cases in age distribution 0-4 years(19.27%),5-14 years(18.30%) and 15
and above years (62.43%) and Malaria prevalence rates by sex show large variation, It ranges
from 65.92% in male to 34.08% in females. But they didnt practiced any preventive methods
such as Environmental management, DDT spray of households, and distribution of bed net for
use to prevent malaria. The only prevention methods used for malaria prevention practiced is to
use modern anti-malarial drugs. Reasons mentioned by the concerned bodies were for not
practiced any intervention was that being there is enough health facilities in the town practicing
any intervention is not as much as important and the regional health bureau did not give us bed
net and DDT for spraying.
Conclusion: The prevalence of malaria in Adwa Town was found to be high which account
13.02% of the total febrile patients and very common in all age groups indicates that malaria is
indigenous to the area. In the town the only intervention use was prompt treatment of the modern
antimalaria drugs but this may have its own effect and could not protect from epidemic. So
comprehensive and integrated methods of intervention is very important.
Recommendations: Thus, design of effective malaria communication strategy; training and
motivation of community health agents and mothers/fathers to treat cases promptly and properly;
and strengthening the link between private-public health sector partnerships with the community
were recommended.

IV.
1. INTRODUCTION

Malaria, the most important parasitic infection of human, affects many people in the world. It is
estimated that the incidence of malaria in the world is between 300-500 million clinical cases per
year (28). Of the estimated 1.5 million to 2.7 million annual deaths from the disease worldwide,
about one million occur among children under 5 years of age in sub-Saharan Africa (28). About
90% of the malaria burden occurs in sub- Saharan Africa, most of which is due to Plasmodium
falciparum (28, 29).

The annual average number of malaria cases reported over the period from 2001 2005 in
Ethiopia was 9.4 million (range 8.4 11.5) while the annual average number of confirmed cases
was 487,984 (range 392,419 591,442). In addition to this, an estimated 36% of the population
is out of the reach of the health service coverage. Therefore, the actual number of malaria cases
that might occur annually throughout the country is estimated to be higher P.falciparum and
P.vivax are the main species accounting for 60% and 40% of malaria cases. Anopheles arabiensis
is the major malaria vector followed by An. Pharoensis (30).

Malaria control is a big challenge due to many factors. The complexity of disease control
process, expensiveness of the control program, resistance of the parasite to antimalarial drugs
and vectors to insecticides are some of the challenge (6).

There is a variation of disease patterns and transmission dynamics from place to place, by season
and according to climate and environmental circumstances. So the approaches in the planning
and implementation of prevention and control activities also vary based on local realities and to
design and implement cost effective appropriate interventions, knowledge on local prevalence
and distribution of malaria is of paramount importance (6).

An estimated 54 million (68%) of the Ethiopian population (80 million as per projection of the
2007 census to July 2010) live in areas where they are at risk for malaria. Each year, health
facilities report 56 million clinical cases of malaria and 1 million confirmed cases. In 2005,
malaria accounted for 15.5% of outpatient visits, 20.4% of total admissions and 27% of total
hospital deaths in the country (7).

In 2002, severe focal outbreaks occurred in the Amhara and Southern Nations and Nationalities
Peoples regions of Ethiopia, resulting in large-scale epidemics in 2003. During that year, 3689
villages in approximately 211 districts were affected, with more than 2 million reported cases
and 3000 deaths in the main regions of the country (Oromiya, Amhara, Southern Nations and
Nationalities Peoples and Tigray regions).(2)

Tigray is found in the northern most regional state of Ethiopia, located between latitude 12 and
15 north. The region has 47 districts (35 rural and 12 urban) in seven zones. The lowest
elevation is at Erob (170 m) and the highest mountain peak at Alaje (3923 m). The region is
divided into northwestern and southern lowlands and central highlands and covers 80 000 km2.
The projected population (from the 2007 census) of the region was 4.6 million in July 2010, with
an estimated growth rate of 2.5% per year (1).
1.
The average temperature ranges from about 22 C in areas below 2400 m to less than 16 C at
higher altitudes; the average temperature in most of the lowland areas where malaria is endemic
is about 27 C. Major population settlement movements are usually from the highlands to the
lowlands, in a search for unexploited, agriculturally rich land. Migration also has a temporal
pattern, highlanders being attracted to the agriculturally rich lowlands in search of seasonal
employment, such as weeding and harvesting; harvesting overlaps with the major malaria
transmission season of September to November. (1)

Almost 75% of Tigray region is malarious, and about the same proportion of the population
resides in these areas and is therefore at risk for malaria. Malaria transmission is seasonal and
depends on both altitude and rainfall. Transmission varies widely with the complex topography,
which ranges from high-altitude plateau and mountainous terrain to deeply incised river valleys
and canyons. At altitudes above 2000 m, the temperature is generally too low to support the
development of the parasite in the mosquito vector. As in the rest of the country, Anopheles
arabiensis is the major malaria vector in the region. It breeds in small sun-exposed pools, mainly
during the rainy seasons (1).

Development of the malaria parasite and vector longevity depends both on temperature and
relative humidity. Favorable conditions for increased transmission prevail after the JuneAugust
rainfall, i.e. in September, October and November, and these months represent the major
transmission season. The unstable nature of malaria makes the region prone to epidemics with
high morbidity and mortality in all age groups, making this disease a major public health
problem. Furthermore, as malaria transmission strikes during the planting and harvesting season,
it adversely affects food security and impoverishes and isolates affected communities. (1, 3)

A better understanding of the dynamic process of urbanization, including urban risk factors for
health, might lead to the development of suitable health interventions and preventive measures
for the rising number of urban inhabitants. Urban malaria is characterized by much greater
heterogeneity, owing to the dynamic demographic and environmental conditions (3).
Consequently, understanding the spatial and temporal pattern of Adwa town malaria risk will
facilitate the design of well-tailored integrated urban malaria control programs. This study focus
why many dwellers of the town were suffering of the disease, and to assess and quantify the
current burden of the disease in the town, finally to identify the influencing factories and to
propose mitigation strategies for the prevention and control of the disease.

2.
2. Literature Review

2.1 Urban malaria in Africa

Malaria can no longer be considered as just a rural issue in Africa. A significant and increasing
proportion of the African population lives in urban areas. There are already 40 cities in Africa
with over one million inhabitants and the United Nations Environmental Programme estimates
that by 2025 there will be 800 million people living in urban areas of the continent. Urban
malaria prevalence rates are highly variable, even within a single city.Prevalences are highest
among the poorest sections of society, since they cannot afford protection from malaria through
improved housing, and are particularly vulnerable to the impact of ineffective diagnosis and
treatment. As urban centers in Africa continue to grow, the scale and impact of urban malaria is
increasing. Despite this threat, control of the problem is feasible: urban malaria is uniquely
amenable to prevention and control as the existing health, planning, agricultural and governance
structures present opportunities (36).

2.2 Malaria morbidity and mortality

Despite Considerable progress in malaria control over the past decade, malaria remains a serious
problem particularly in Sub Saharan Africa. An estimated 300 million to 500 million cases and
1.5 to 2.7 million deaths occur worldwide each year due to malaria, and over 2400 million
remain at risk(1) . In the last decade, the prevalence of malaria has been escalating at an alarming
rate, especially in Africa. One of four childhood deaths in Africa is caused by malaria and 80%
of global malarial morbidity and 90% of malarial deaths occur in Sub Saharan Africa (28, 29).

Dramatic reductions in the annual parasite index (API) achieved by pilot IRS projects in many
parts of the world inspired the world Health Assembly to adopt malaria eradication as a goal in
1955. However, the goal of eradication proved elusive in most malaria endemic countries in the
tropics (25, 26). A number of factors appear to be contributing to the resurgence of malaria
which include: resistance of parasite to drugs, conflicts forcing mass migration of people to or
from malaria endemic areas, migration of non immune people to endemic areas for agricultural
reasons, changing rainfall patterns favoring mosquitoes breeding, adverse socioeconomic
conditions leading to inadequate health budget to fight malaria, high birth rate leading to a rapid
increase in susceptible population of under 5 children and changes in behavior of vectors and
resistance to insecticides(27 ).

In Ethiopia, malaria stands as the leading cause of morbidity and mortality where three quarters
of the landmass is regarded as malarious and nearly 68% of the total population lives in malaria
risk areas (30). In 2003 the disease was the primary cause of reported morbidity and mortality
accounting for 15.5% of out patient visits, 20% of hospital admissions and 27% of hospital
deaths (31). Malaria transmission in Ethiopia is unstable and characterized by frequent and often
large-scale epidemics (30, 32). In 2003, large scale malaria epidemics occurred from April to
December resulting in 2 million clinical and confirmed cases and 3000 deaths, affecting 3368
localities in 211 districts (30).

3.
Malaria is a major public health problem in Ethiopia every year; its one of the leading causes of
outpatient consultations, admissions and death before 2005. However, recently the rapid scale up
of interventions has brought about significant decline in malaria burden for example in 2006/7, it
became the 6th cause of outpatient consultations and Malaria epidemic report also reduced
dramatically (37).

Changes have been observed in the epidemiology of malaria through time even though the
admission and death decreases. Previously, malaria was known to occur in areas below 2000m
a.s.l, but currently it has been documented to occur indigenously even in areas above 2400m
a.s.l,. Plasmodium falciparum is the dominant species followed by P. vivax, these two species
account for 60% and 40% of all malaria cases respectively. However, the relative frequency of
the species varies from place to place and from season to season (7).

2.3Prevention and control

Prevention and control activities as guided by the National Strategic Plan (2006-2010) include:
I) Early diagnosis and effective treatment
II) Selective vector control mainly through the use of ITNs and IRS,
III) Epidemic prevention & control IV) IEC & BCC on malaria
V) Human resource development VI) Health Management & Information System
VII) Monitoring & evaluation VIII) Operational Research (30).

Physical health service coverage of Ethiopia is 64% and a significant segment of the population
does not utilize the already available health services due to different (31). Studies have shown
that Plasmodium falciparum malaria was resistant to Sulphadoxine-pyremethamine (SP) this had
been the first line anti malarial drug for the past few years (33). This has been triggered a shift to
more effective antimalarial, particularly, Artemisinin combination therapy (ACT); now the first
line treatment for uncomplicated falciparum malaria is Artemether Lumefantrine (33).

Chemical spray of houses is done just before the transmission season to prevent epidemics and
check seasonal peaks. DDT is used for indoor spraying of houses and organophosphates use is
limited to areas where DDT resistant vectors are detected. As the trend of malaria changes over
time, there should be a strong monitoring system for the effectiveness of the insecticides used
(32).Insecticide treated nets (ITNs) are used for personal protection against malaria.
Currently,ITNs are provided at highly subsidized price or free of charge, to population groups at
higher risk such as non - immune settlers moving to malaria endemic areas, children under five
years and pregnant women (33). Estimates of ITNs coverage from a national survey show that
household ITNs possession (at least one ITN per household) was 24 %( 22).

4.
2.4 Prevalence of malaria
Point prevalence of malaria, expressed by the parasite rate, is by far the most commonly
available measure of malaria endemicity. It has been widely used as proxy for transmission
intensity over several decades (23). The principal drawback to using parasite rate is that they are
liable to vary significantly over time, particularly in areas of unstable malaria transmission.
Some of variability associated with parasite rates can be avoided by using spleen rates (the
prevalence of enlarged spleens). These reflect chronic and latent infections in partially immune
hosts and as such provide an indication of prevailing levels of malaria endemicity in the sample
population (23, 24).

A study conducted in Khartoum has shown parasite rate of 0.21%and spleen rate of 0.17 %( 34).
From cross sectional malaria prevalence surveys in Southern Mozambique, parasite rate and
spleen rate were 35.3% and 23% respectively, in the first survey( Feb1997) and in the second
survey conducted in October 1997 the parasite rate was 24.2%,while, the spleen rate was 24.9%
showing little variation in contrast to the parasite rate (17). In another study conducted in Prabis,
Guinea-Bissau level of malaria endemic determined using parasitemia and spleen rate during
rainy and dry seasons revealed that 49% of villages during rainy season and 71% of villages
during the dry season were mesoendemic as measured by the parasite rate. Where as, 92% of the
villages during the rainy season and 90% of the villages during the dry season were
mesoendemic as measured by spleen rate (16).
2.5 Age dependence of malaria

Many studies have shown that malaria is not a common cause of death among children under the
age of 6 months and that in malaria endemic areas; very young infants rarely contract malaria
(15, 13). This protection has mainly been attributed to transplacentally acquired malaria
antibodies, as well as to other biological factors. However, after six months of age, unprotected
infants suffer repeated and severe attacks that become milder as they grow older. A study in
Nigeria; first infections were contracted during the second half of the first year of life (13). These
findings also showed that malaria parasite rates and densities increased rapidly until the age of 6
months and thereafter decreased gradually until one year of age. Otherwise, the proportion of
infected infants increases with age, with a tendency to increase from six months and the
prevalence of hyperparasitaemia (parasite density greater than 10 000 ml) also shows an increase
with age over the first 6 months in an area of very high transmission intensity (14).

In all areas of high malaria endemicity, the incidence of clinical malaria is highest in young
children (under two years of age) with an average of two to six malaria attacks per year (35) and
both the incidence and the severity of the disease decreases considerably there after. By the age
of five years, immunoprotection is reflected by a low rate of malaria attacks despite frequently
high parasite densities (13).

5
2.6 Climatic and geographical parameters and malaria
Malaria is governed by a large number of environmental factors, which affect its distribution,
seasonality and transmission intensity (21).The peak in morbidity and mortality is generally
obtained in the rainy season, the time when malaria transmission is at its peak, and the number of
deaths during this period has been shown to be over threefold higher than in the rest of the year
(20).

The relationship between malaria vector density and the distance of a settlement from a river is
an important indicator of malaria transmission. In The Gambia ITN study, there was an inverse
relationship between the numbers of mosquitoes in a village and the distance of settlement from
the river (19)

2.7 Mosquito net use and malaria

A close association has been observed between peoples perception of the cause of malaria and
the type of protective measure used. In a longitudinal cohort study in Kenya, 8.5% of women
reported using a bed net regularly, 17.5% burned mosquito coils, 2.7% used an insecticide spray,
and 12.1% reported burning dung or leaves. Overall, 67% of the women reported not taking
protective measures on a regular basis, and only 5% reported using more than one method
regularly (12).

An intervention trial conducted in young children (1-9 years) in a rural area of The Gambia to
assess the impact of the traditional use of bed nets on malaria morbidity has found no significant
difference in the incidence of clinical attacks of malaria or in any other malariometric
measurements between the 2 groups of children (one group sleeping under bed nets and the
second without bed nets). Thus, bed nets were considered not very effective in reducing malaria
morbidity in this group of children (18).

On the other hand, other studies on Insecticide Treated Nets (ITN) undertaken in different
African and Asian countries have consistently documented significant reduction in the rate of
malaria parasitaemia and malaria morbidity (10, 11).In order to plan and implement cost
effective malaria prevention and control activities, the importance of accurate information on the
epidemiology of malaria is unquestionable. Accordingly, there was no community based study
which shows the true picture of prevalence of malaria and its influencing factors in Adwa town
and I never used community based study due to constrain of time, budget etc. Therefore, in this
study I used parasite rates and structured interview questions only to measure prevalence and its
influencing factors in the study area (11).

6
3. Objective
3.1 General objective
The purpose of the study was to estimate prevalence of malaria in febrile patients in health
facilities of Adwa Health center and Adwa Hospital and to identify factors influencing it.

3.2 Specific objective

To estimate the prevalence of malaria in febrile patients in health facilities of Adwa

Health center and Adwa Hospital
To identify factors influence it
4. Materials and Methods
4.1) Study Design
The study design was a retrospective study based on the health institution records from register
books and data from key informants.
4.2) Study Area
The study was conducted in Adwa town; central zone of Tigray.And situated on an area of 105
Km 2, with nine kebeles. It has a population of more than 43,616 according to the 2007 census
projection on July 2009. Almost all the Kebeles are malarious; and population at risk is 64%.
The health service geographical coverage is around 100%.

The town has two health center (one started before three months), one hospital, 6 private clinics
and 11 private drug vendors and Malaria diagnostic laboratories are found at the health center,
hospital and clinics.

4.3) Study Population

The study subjects included all febrile patients who are diagnosis for malaria in 2008/09 in the
Health center and Hospital from the Registration book.
4.3.1 Inclusion Criteria: The study subjects must be permanent dwellers of the study area (Adwa
town) from the health facilities address of registration books.

4.4) Sample size determination

4.4.1Quantitative
The formula for calculating sample size is: n = Z (/2)2 p (1-p)/d2 but all febrile
patients in the register book was consider as part of the study
Assumptions
Based on the health facilities data,
C.I=95% =0.05
Precision (d) =0.03

7
 4.4.2Qualitative

Key Informant (KI) interviewing: Key informants were interview as much as redundant
information. The types of key informants were:
1. Health workers from the formal sector that primarily treat malaria
2. Pharmacy technician who works in drug store,
3. Wereda health administrators

4.5) Data Collection Procedures

Data were collected by reviewing registration books and key informant interviews.
.
4.5.1 Key Informants Interviews
Key informant interviews were conducted using semi-structured interviews guides, by the
principal investigator. This was a written list of questions or topics that need to be covered
during the interview. The interview guide contains clear instructions concerning the main
questions to be asked or topics to be probe, though the interviews.

4.6) Quality Control

The study methods and conclusions were assured using a blend of qualitative and quantitative
methods. Selectivity bias was avoided using appropriate sampling procedure and
representativeness of the qualitative data was ensuring using homogenous groups. But it was
really very difficult.

4.7) Data Analysis procedures

4.7.1Quantitative
The data was analyzed using simple calculation like calculator and computer desktop

4.7.2Qualitative
The qualitative data was analyzed manually. Principal investigator was analyzed Key Informant
of interviews Data.

4.8) Ethical Consideration

Before conducting the survey, a supporting letter that was written from the Department of public
Health of Mekelle University (Ayder college of Health science) was give to the Adwa District
Health Office, and discussion was held with the respective health management team to brief the
purpose of the study. And the results of the study will be disseminating in the form of
presentation, hard copies of the report, and in the form of publication to the general public.

8
5. Results
Malaria morbidity and mortality data in Adwa town are collected on monthly basis. The original
datasets and monthly reports were available at the Health center and Hospital but their accuracy
and completeness could, therefore, not be ascertained specially in the hospital. The available
reports summarized all the clinical diagnoses in public health facilities were 2008/09,
differentiating of the malaria cases was done by age,address,species and sex,but there was no
information on how many private health facilities reported regularly to Hospital and the health
center. And those were some of the information found in the town:

5.1 prevalence of malaria in the Health center

Table 1: prevalence of malaria from Adwa Health center 2008/09 Data

So.no category number Malaria by Age category number
1 Total clients 8245 13 Malaria cases 235
2 Febrile patients 3161 14 0-4 years 14
Percentage (%) 38.33 Percentage (%) 6.0
3 Total clients 8245 15 Malaria cases 235
4 Malaria cases 235 16 5-14 years 32
Percentage (%) 2.85 Percentage (%) 13.6
5 Febrile patients 3161 17 Malaria cases 235
6 Malaria cases 235 18 >=15 years 189
Percentage (%) 7.43 Percentage (%) 80.4
7 Malaria cases 235 Sex ratio
8 PF 217 19 Malaria cases 235
Percentage (%) 92.34 20 Male 186
9 Malaria cases 235 Percentage (%) 79.15
10 PV 16 21 Malaria cases 235
Percentage (%) 6.81 22 Female 49
11 Malaria cases 235 Percentage (%) 20.85
12 Mixed 2
Percentage (%) 0.85

In 2008/09, there were 235 simple malaria cases (2.85% of total clients in 2008/09), malaria
cases from all febrile patients (7.43%) and plasmodium falciparium from all malaria cases
(92.34%), plasmodium vivax from all malaria cases (6.81%), and mixed from all malaria cases
(0.85 %), and Unfortunately it is not possible to know whether these trends were real or linked to
reporting differences because of incompleteness of the data due to different reasons and malaria
is very common in all age groups but very high on age >=15 years(80.4%).

9
 5.2 prevalence of malaria in the Hospital

Table 2: prevalence of malaria from Adwa Hospital 2008/09 Data

So.no category number Malaria by Age category number
1 Total clients 5780 13 Malaria cases 481
2 Febrile patients 2335 14 0-4 years 124
Percentage (%) 40.40 Percentage (%) 25.78
3 Total clients 5780 15 Malaria cases 481
4 Malaria cases 481 16 5-14 years 99
Percentage (%) 8.32 Percentage (%) 20.58
5 Febrile patients 2335 17 Malaria cases 481
6 Malaria cases 481 18 >=15 years 258
Percentage (%) 20.60 Percentage (%) 53.64
7 Malaria cases 481 Sex ratio
8 PF 424 19 Malaria cases 481
Percentage (%) 88.15 20 Male 286
9 Malaria cases 481 Percentage (%) 59.50
10 PV 57 21 Malaria cases 481
Percentage (%) 11.85 22 Female 195
11 Malaria cases 481 Percentage (%) 40.50
12 Mixed 0
Percentage (%) 0.00

In 2008/09 in the Hospital, there were 481 malaria cases (8.32% of total clients), malaria cases
from all febrile patients (20.60%) and plasmodium falciparium from all malaria cases (88.15%),
plasmodium vivax from all malaria cases (11.85%), and mixed from all malaria cases (0.85 %),
and malaria cases were high in hospital than in the health center but Unfortunately it is not
possible to know whether these trends were real or linked to reporting differences due to
incompleteness and low data quality. Even though malaria was common to all age group but very
common on age >=15 years (53.64%).

5.3 prevalence of malaria in the town

Table 3: prevalence of malaria in Adwa Town a combination of the two health facilities 2008/09

So.no category number Malaria by Age category number

1 Total clients 14025 13 Malaria cases 716
2 Febrile patients 5496 14 0-4 years 138
Percentage (%) 39.20 Percentage (%) 19.30
3 Total clients 14025 15 Malaria cases 716
4 Malaria cases 716 16 5-14 years 131
Percentage (%) 5.10 Percentage (%) 18.30
5 Febrile patients 5496 17 Malaria cases 716
6 Malaria cases 716 18 >=15 years 447
Percentage (%) 13.03 Percentage (%) 62.40
7 Malaria cases 716 Sex ratio
 8 PF 641 19 Malaria cases 716
Percentage (%) 89.52 20 Male 472
9 Malaria cases 716 Percentage (%) 65.92
10 PV 73 21 Malaria cases 716
Percentage (%) 10.20 22 Female 244
11 Malaria cases 716 Percentage (%) 34.08
12 Mixed 2
Percentage (%) 0.28
 Chart 1: A bar graph for prevalence of malaria cases in Adwa town 2008/09
Number of clients

Number malaria cases and its species

In 2008/09, in the two health facilities there were 716 malaria cases (5.10% of total clients in
2008/09), malaria cases from all febrile patients (13.02%) and plasmodium falciparium from all
malaria cases (89.53%), plasmodium vivax from all malaria cases (10.20%), and mixed from all
malaria cases (0.28 %), and Unfortunately it is not possible to know whether these trends were
real or linked to reporting differences due to different reasons(low data quality, incompleteness
of data, low information linkage between private health facilities etc).

11
Chart2: Age distribution of malaria cases in Adwa town 2008/09

800
716
716
700 716

600
all malaria cases
500 0-4 years
400 447 %
all malaria cases
300
5-14.0 years
200
138 %
131
100 all malaria cases
19.3 >=15 years
0 18.30 62.4
%

Malaria by age distribution

All the data were divided into three age groups: 0-4 year old, 5-14years,and > =15 years and the
overall prevalence rates of parasitaemia of malaria cases in the age distribution was 0-4
years(19.27%),5-14 years(18.30%) and 15 and above years (62.4%). The fractions of malaria-
attributable fevers could not be calculated using the standard formula for the infants and children
aged six to 15 years (because of the division by zero), but since the cases did not have any
parasites, the fractions were equaled to zero. And malaria was very common on age 15 and
above due to different reasons.

12
Chart 3: malaria cases by sex in Adwa town 2008/09

malaria cases by sex in Adwa town 2008/09

500 472
450

400
NO.of malaria cases

65.92
350
%
300
244 male
250
Female
200
34.08%
150
100

50

0
sex

Malaria prevalence rates by sex show large variation. It ranges from 65.92% in male to 34.08%
in females. This was due to move moment of male from place to place, male behavior of sleep
(in the field for harvesting, outside home due to different reasons etc.).But additional
investigation is needed for sex variation.

5.4 Major Findings from the qualitative data (FGD)

5.4.1 Perception about the magnitude of malaria and its impacts
Malaria was identified by all the participants of the FGDs as one of the major health problems
affecting the community. The peak occurrence of the disease was mostly observed during
September to December, and caused great loss on the household income according to the
majority of the discussants. The participants further elaborated that the impact of the disease was
resulting in incapacitation and death if effective treatment was not sought.
5.4.2 Major methods of prevention and control of malaria
Almost All the health professionals and other health administers involved in the FGDs
mentioned that draining, filling and clearing of the breeding places for mosquitoes could prevent
malaria. It could also be prevented by indoor residual spraying of houses by insecticides and use
of ITNs and this method was cited as the best of all methods for prevention and control of
malaria. But the only method introduce was only use of prompt treatment for malaria cases the
reason mentioned by the head of the Adwa town health office head was the town has enough
health facility and still we never see any malaria epidemic, so we can control the disease with out
any other complex interventions and the regional health bureau didnt gave us any DDT or ITNs,
so we are try to the best of our ability .But to the opposite to this the Adwa Hospital CEO
mentioned that we were to late in introducing of major preventive methods of malaria in the
town and we know the town is a malariaous area from its altitude(1850m) and malaria burden of
clients and the health didnt try to introduce any method like other rural settings, so better to say
lets run to introduce the basic methods before a devastating effects come.
13
6. Discussion
During its months operation, the malaria prevalence research provided many lessons that should
be considered for future malaria control initiatives in Adwa town. The study clarified that 1)
malaria control in urban settings can be achieved by a combination of multiple interventions,
namely vector control and rapid diagnosis and treatment; 2) community health education and
active participation is a crucial step for reduction in malaria incidence, prevalence, and successful
surveillance; and 3) Having complete, timely and best quality data can help in the identification
of influencing factories in the prevalence of malaria and plays a key role in targeting control
strategies.

The findings of this study have also serious implications for the assessment of the burden of
malaria in the town, since the routine statistics seriously inflate the true situation. So the results
of study revealed that malaria parasite rate was 13.02% from febrile patients which shows that
the town is a malarious area. And of all the malaria case 62.40% were in the age category >=15
years which shows malaria affects fertile age group which is highly related with a country
economic development. But surprisingly the burden of disease was high in the age category of 0-
4years (19.30%) than the age category 5-14 years (18.30%) which is contrasting to most study
held in different countries, so this needs further study to investigate the reason behind it. And
Similar to other urban study almost 90 %( 89.52%) of the malaria cases were PF and the
remaining was PV this was a normal behavior of malaria cases especially in Africa.

Of the 716 malaria cases 472 (65.92%) were male and the remaining 244(34.08%) female. This
data shows that male were very vulnerable to malaria almost by two fold than female but the
reason behind may need further study and many literatures shows that pregnant mothers and
children less than five years are very vulnerable to the disease .

Because of poor documentation and deficiencies in reporting, and not having community based
study the routine health data do not reflect the reality in Adwa that is why our review also shows
that the epidemiology of malaria in the town didnt not fully comparable to what is well
established for rural settings.

Finally the Current malaria control strategy in the town settings consist of only early diagnosis
and prompt treatment. But this may have its own effect in drug resistance and limitation in
prevention of epidemics, so I propose to strengthen these programs in combination with other
interventions like environmental management as a key feature for sustainable mitigation of the
burden of malaria in the town. Interventions that consider the different facets of the urban
environment have the potential to be broadly applicable and affect the health of many
inhabitants.

14
7. Conclusion and Recommendations

7.1 conclusions
The prevalence of malaria in Adwa Town was found to be high. The prevalence was strongly
associated with proximity of residence to potential mosquito breeding sites like presence of
micro-dam, many streams in the town. The occurrence of the disease among all age group would
indicate that malaria is indigenous/endemic to the area. So Use of personal protection methods
such as insecticide treated mosquito nets and environmental protection should be start as soon as
possible and malaria control interventions should target residents who are at a closer proximity to
mosquito breeding sites.

7.2 Recommendations

Urban malaria is already a problem and is likely to increase as urbanization continues. In

order to avert an increase in disease burden, concerted action needs to be taken quickly
and promptly.
malaria control in urban settings can be achieved by a combination of multiple
interventions, namely vector control and rapid diagnosis and treatment
There is a need to target the most vulnerable sections of society who suffer a double
burden of insufficient protection from malaria transmission due to inadequate housing
and living conditions.
Inter-sectoral interventions are the key to successful urban malaria control and must
include close collaboration between water,agriculture,urban planning and health
Existing health and governance structures in urban environments need to invest in
programmes to manage urban malaria effectively using established methods and tools for
mosquito control and malaria prevention, diagnosis and treatment.
Community health education and active participation is a crucial step for reduction in
malaria incidence, prevalence, and successful surveillance.
Prevalence of malaria in a certain area can be know using health facilities integrated data
and other available materials, so Adwa Hospital has many problems in data quality,
completeness etc so this must give more attention and absolutely to use the HMIS format.

15
References
1) World health organization, Deployment of artemether-lumefantrine with rapid diagnostic
tests at community level Raya Valley, Tigray, Ethiopia. Global Malaria program, JUNE
2009, Project report April 2005June 2007:1-2.
2) Tesfaye T and Deressa W.Prevalence of urban malaria and associated factors in Gondar
Town, Northwest Ethiopia.2007, 5-7.
3) Swiss Tropical Institute (STI), Epidemiology of urban malaria in Cotonou (Benin) .Rapid
Urban Malaria Appraisal (RUMA) IV, .2006, 23-25 Switzerland.
4) Yohannes M, Petros B .Urban malaria in Nazareth. Ethiopia. parasitological
studies,2007,1
5) Woyessa A et al. Malaria in Addis Ababa and its environs: assessment of magnitude and
distribution. Ethiop.J.Health Dev. 2002; 16(2):147-155.
6) Alemu G.Prevalence of Malaria and its influencing factors in Awassa District,
Southern Ethiopia. 2006, Addis Ababa, Ethiopia, 5-6.
7) Demographic and Health Survey, Addis Ababa, Ethiopia, 2005.
8) Malaria report for the fiscal year 2004/5, Malaria and other vector borne diseases
prevention and control unit, Tigray, Ethiopia, 2005
9) Assessment of ITNs and Entomological Surveys for Malaria Control in
Tigray(unpublished), Tigray Region Malaria Control Department Miazia 22-26/99E.C
10) Ranque et al. Abstr. XI International Congress on Tropical Medicine and malaria.1984
11) Roosendaal J.A. Impregnated mosquito nets and curtains for self-protection and vector
control. Tropical Diseases Bulletin.1989; 86, 1-39.
12) Bloland P.B., Ruebush T.K., McCormick J.B. et al. Longitudinal cohort study of the
epidemiology of malaria infections in area of intense malaria transmission. Description of
the study site, general methodology, and study population. American Journal of Tropical
Medicine and Hygiene.1999; 60 (4): 635-640.
13) Akum Achidi E., Salimonu L.M., Azuzu M.C. et al. Studies on Plasmodium Falciparum
parasitemia and development of anemia in Nigerian infants during their first year of life.
American Journal of Tropical Medicine and Hygiene. 1996; 55 (2): 138-143.
14) Kitua A.Y., Smith T., Alonso P.L. et al. Plasmodium falciparum malaria in the first year
of the life in area of intense and perennial transmission. Tropical Medicine and
International Health.1996; 1(4):475-484.
15) Alonzo P.L. et al. A malaria control trial using insecticide-treated bed nets and targeted
chemoprophylaxis in a rural area of the Gambia, West Africa 2. Mortality and morbidity
from malaria in the study area. Transactions of the Royal Society of the Tropical
Medicine and Hygiene.1993; Supplement 2, 13-17.
16) Aldina G. et al. The epidemiology of malaria in Prabis, Guinea-Bissau. Mem
InstOswaldo Cruz. 1996; 91(1):11- 17.
17) Francisco S. et al. Malaria in southern Mozambique: malariometric indicators and
malaria case definition in Manicha district. Transactions of the Royal Society of Tropical
Medicine and Hygiene.2003; 97:661-666.
18) Snow R.W., Lindsay S.W., Hayes R.J. et al. Permethrin-treated bed nets prevent malaria
in Gambian children. Transaction of the Royal Society of Tropical Medicine and
Hygiene.1988; 82, 838-842.

16
19) Lindsay S.W., Alonso P.L., Amstrong Shellenberg J.R.M., et al. A malaria control trial using
insecticide treated bed nets and targeted chemoprophylaxis in a rural area of The Gambia, West
Africa.1.Entomological characteristics of the study area. Transactions of the Royal Society of
Tropical Medicine and Hygiene, 1993; 87(2): 19-23.
20) Jaffar S., Leach A., Greenwood A.M. et al. Changes in the pattern of infant and childhood
mortality in Upper River Division, The Gambia, from 1989 to 1993. Tropical Medicine and
International Health.1997; 2 (1): 28-37.
21) Snow R.W., Craig M., Deichmann U. et al. Estimating mortality, morbidity and disability due to
malaria among Africas no-pregnant population. Bulletin of the World Health Organization.1999;
77: 624-640.
22) Demographic and Health Survey, Addis Ababa, Ethiopia, 2005.
23) Lindsay SW, Martens P. Malaria in the African Highlands: past, present and future. Bulletin of
the World Health Organization.1998; 76: 33-45.
24) Bruce-Chwatt, L. J. Essential Malariology, 2nd edition. London: William Heinemann Medical
Books Ltd.1986.
25) Krogstad DJ. Malaria as a reemerging disease, Epidemiology Rev 1996; 18:77-89.
26) Test procedures for insecticide resistance monitoring in malaria vectors, Bioefficacy and
persistence of insecticides on treated surfaces; Report of the WHO informal consultation. WHO,
Geneva, Switzerland: 1998(WHO/CDS/CPC/MAL/98.12).
27) Thomas c. Echidna. Malaria: A Reemerging Disease in Africa. Emerging Infectious Diseases:
NCID, CDC, Atlanta, GA; July-Sept. 1998:4(3).
28) World Health Organization. Investing in health research for development. Report of the AdHoc
committee on Health Research Relating to future Intervention options. Geneva: The
Organization; 1996. Report No;TDR/Gen/96.1.
29) Implementation of the Global Malaria Control Strategy. Report of a WHO Study Group on the
Implementation of the Global Plan of Action for Malaria Control 19932000. Geneva, World
Health Organization, 1993 (WHO Technical Report Series, No.839).
30) National five- year strategic Plan for malaria prevention & control in Ethiopia; 2006-2010,
FMOH, 2006.
31) Health and Health related Indicators; planning and programming Department, MOH, 2003/04.
32) Ministry of Health, Guideline for malaria vector control in Ethiopia; malaria and other vector
born diseases prevention and control team Diseases prevention & Control Department, MOH,
Addis Ababa 2002
33) Center for National Health Development in Ethiopia, Proposal for the Global Fund to Fight
AIDS, Tuberculosis and malaria, second round, 2003.
34) Malik E.M. et al. Stratification of Khartoum urban area by the risk of malaria transmission.
Eastern Mediterranean Health Journal.2003; 9(4):559-569.
35) Trape J.F., Rogier C., Konate L. et al. The Dielmo Project: a longitudinal study of natural
malaria infection and the mechanisms of protective immunity in a community living in a
holoendemic area of Senegal American Journal of Tropical Medicine and Hygiene.1994; 51 (2):
123-137.

17
36) Liver pool school of tropical medicine, urban malaria in Africa.2004:1
Website: www.liv.ac.uk/lstm/majorprogs/malaria/outputs.htm
37) Tesfaye G.Training of health workers on malaria.Adma,Ethiopia,01 February 2010:slide 51
 Annex 1: Letter of consent

Mekelle University and Addis continental institute of public Health joint MPH program
Department of Public Health

CONSENT OF THE INTERVIEWEE

Hello? I am ..from Mekelle university, I am here to study about the

prevalence of Malaria in Adwa town. I will ask you some questions related to malaria and take
datas of 2008/09 from your health facility of the laboratory registration book. Please be assured
that the information will be confidential since I do not register names and if you are observed
any in convince you can stop or give any suggestion to the investigator at any time. At this time
do you want to ask me anything about this study?

Do I have your agreement in the study ____________ (yes or no?)

Signature_____________

Annex 2: Structural interview for Health administrators

1) Is Adwa town a malarious area?

a) Yes b)no
2) If so could you tell the trend?
3) Have you introduce any intervention?
4) What intervention do you use?
5) Do you observe any challenge for introducing the intervention?
6) Any suggestion you want to say

Annex 3: Laboratory results reporting format

Name of Health Facilities

S.no age sex address species Age category months

M F PF PV mixed 0-4 5-14 >=15

1
2
3
4

18