Facility-based Retrospective Study on Malaria in Wondo Genet, Sidama

Regional State, South Ethiopia

By:

Kassahun Lemma

A Thesis Submitted to School of Graduate Studies of Addis Ababa University in

Partial Fulfillment of the Requirements for Degree of Master of Science in
Biology (General Biology)

September 2021
Addis Ababa, Ethiopia
TABLE OF CONTENTS
ACKNOWLEDGEMENT ........................................................................................................................... IV

LIST OF TABLES ........................................................................................................................................ V

LIST OF FIGURE........................................................................................................................................ VI

Acronyms .................................................................................................................................................... VII

ABSTRACT............................................................................................................................................... VIII

1. INTRODUCTION .................................................................................................................................... 1

1.1 Background ......................................................................................................................................... 1

1.2 Statement of the problem .................................................................................................................... 2

1.3 Objectives ........................................................................................................................................... 3

1.3.1 General Objective ........................................................................................................................ 3

1.3.2 Specific Objectives ...................................................................................................................... 3

1.4 Significance of the study ................................................................................................................. 3

1.5 Limitation of the study ........................................................................................................................ 4

2. REVIEW OF RELATED LITERATURE ................................................................................................ 5

2.1 Global burden of malaria .................................................................................................................... 5

2.2 Malaria in Ethiopia………………………………………………………………………………………………………………………..5

2.3 Etiology of malaria Disease ................................................................................................................ 7

2.4 Transmission and Life cycle ............................................................................................................... 8

2.5 Signs and symptoms of malaria .......................................................................................................... 9

2.6 Diagnosis and treatment .................................................................................................................... 10

3. MATERIALS AND METHODS ............................................................................................................ 12

3.1 Description of the study Area ........................................................................................................... 12

3.2 Study Design ..................................................................................................................................... 14

3.3 Data Collection ................................................................................................................................. 14

II
 3.4 Data Analysis .................................................................................................................................... 14

3.5 Ethical Considerations ...................................................................................................................... 14

4. RESULTS ............................................................................................................................................... 15

4.1. Annual Trends of Malaria Prevalence ............................................................................................. 15

4. 2. Prevalence of malaria with respect to sex and age groups .............................................................. 16

4.3. Seasonal variation of malaria prevalence at Wondo Genet Health Center (2015-2019) ................. 18

4.4 Discussion ......................................................................................................................................... 19

5. CONCLUSIONS AND RECOMMENDATIONS ................................................................................. 21

5.1. Conclusions ...................................................................................................................................... 21

5.2 Recommendations ............................................................................................................................. 21

REFERENCES ........................................................................................................................................... 22

III
 ACKNOWLEDGEMENTS

I am grateful indeed to the Almighty GOD, the Merciful and Compassionate. Second, I express
my deepest gratitude to my advisor Hassen Mamo (PhD) for his constructive and consistent
follow-ups and guidance throughout the work devoting their valuable time. Third, I would
like to my special thanks to Wondo Genet health office workers that gave me relevant
information about the prevalence of malaria in their health center. Fourth, I would like to
thanks Institute of Review Board of Addis Ababa University for constrictive comments and
MOSHE for financial support. Lastly, I would like to thank my family, relatives, friends and
others who helped me and contributed helpful and smart on advice in accomplishing my thesis.

IV
List of Tables
Table 1: Slide-confirmed annual malaria cases and distribution of Plasmodium species in Wondo Genet
(2015 - 2019)............................................................................................................................................... 16

Table 2: Sex distribution of malaria cases by sex at Wondo Genet Health Center, Wondo Genet, South
Ethiopia (2015 - 2019) ................................................................................................................................ 17

Table 3: Distribution of malaria slide-confirmed cases in Wondo Genet Health Center in Wondo Genet
(2015 - 2019)............................................................................................................................................... 18

Table 4: Seasonal variation of malaria prevalence in Wondo Genet, south Ethiopia (2015 - 2019) .......... 19

V
List of Figures

Figure -1: Map of study area ....................................................................................................................... 14

Figure-2: Annual malaria cases and distribution of Plasmodium species in Wondo Genet (2015 - 2019) 17

VI
Acronyms

ACT Artemisinin-based combination Therapy

CDC Centre for Disease Control and Prevention

CFR Case Fatality Rate

CQ Chloroquine

FNOH Federal Ministry of Health

HEWs Health Extension worker

HSDP Health Sector Development Program

IRS Indoor-Residual spraying

ITNs Insecticide Treated Net

LLIN Long Lasting Insecticidal Nets

MIS malaria Indicator Survey

MOH Ministry of Health

MOP Malaria Operational Plan

MOSHE Ministry of Science and Higher Education

PCR Polymerase chain Reaction

RDT Rapid Diagnostic Test

SNNPRs Southern Nation, Nationalities and Regional States

UNESCO United Nations Educational, Scientific and cultural Organization

USAID United States Agency

VII
ABSTRACT
Currently, malaria is a widely prevalent and poses a serious challenge although elimination is the
agenda. The main objective of the study was retrospective assessment of malaria in health-
facilities of Wondo Genet district, Sidama Regional state, south Ethiopia. A retrospective design
was employed in order to gather information. This was done by reviewing the past five-year
(2015-2019) malaria morbidity records of the district. During this period a total of 15,218 thick
and thin Giemsa stained blood films were examined and 3530 (23.20%) microscopically
confirmed malaria cases were reported as a decreased inter-annual trend. Plasmodium vivax and
plasmodium falciparum accounted for 50.9% and 49.1% of the cases respectively. Although
malaria was reported in all age groups and both sexes, ≥15 year age group and males were more
affected. However, the prevalence of malaria infection between males and females was not
statistically significant (P>0.05) and, not among age groups. Despite the apparent seasonal
fluctuation of malaria trends in the area, the peak of malaria cases was reported during June,
August and September within the last five years. Although malaria was in a decreasing trend, it
remained a significant public health threat in this particular area. Therefore, intervention
measures need to be strengthened to effectively reduce the burden of malaria in Wondo Genet.

Keywords: Malaria, Plasmodium, Prevalence, Retrospective study, Wondo Genet

VIII
1. INTRODUCTION

1.1 Background

Malaria is an infectious disease that has a major impact on global public health and the economy,
with an estimated 3.4 billion people at risk. Currently, malaria threatens almost one third of the
world‟s population in 104 tropical countries and territories where it is considered an endemic
disease. The World Health Organization (WHO) estimates that 207 million cases of malaria
occurred globally in 2012 and led to 627,000 deaths. Africa, South-East Asia and the Eastern
Mediterranean were the regions with the highest numbers of reported cases and deaths reported,
mainly in children under five years of age (WHO 2013). Malaria is caused by a protozoan
belonging to the genus, Plasmodium, which are obligate intracellular protozoa. P.
falciparum (60%) and P. vivax (40%) are the two key causes of malaria. P. falciparum, P. vivax,
P. ovale, P. malaria, and P. knowlesi infect humans and P. falciparum is the most highly virulent
species and is responsible for nearly all of the 1.7–2.5 million deaths worldwide caused by
malaria and P. falciparum remains the single most important threat to public health at a global
scale, accounting for more than 90% of the world‟s malaria mortality (Baird, 2013).
Mosquitoes of the Anopheles genus are the vectors of the Plasmodium species, the causative
agents of malarial disease. More than 400 species of the Anopheles mosquito have been
described and approximately 70 these species are potential vectors of malaria that affect humans
(Sinka et al. 2012).

In Ethiopia, malaria burden have been reduced over the last two decades due to improved
coverage of key malaria interventions through-out the country (FDREMH report, 2015 and
Tafesse et al, 2018). Even though these gains, in the previous years, malaria still remains the
leading cause of outpatient visits, health facility admissions and inpatient deaths (FMOH, 2012).
In 2016, there were an estimated 2,927,266 new malaria cases and 4782 deaths (Girum et al,
2016). Furthermore, 30% of the overall disability adjusted life years (DALYs) are lost, making it
a significant impediment to social and economic development (PMI, 2008). The most
predominant and widely distributed parasites in Ethiopia are P. falciparum and P. vivax,
constituting 60% and 40% of malaria cases, respectively (FMOH, 2012).

1
Around 68% Ethiopian landmass is considered endemic for malaria, putting 60% of the total
population more at risk of contracting the disease (EPHIENMIS, 2016). The transmission
intensity and levels of malaria risk show marked seasonal, inter-annual and spatial variability;
with the exception of the southwestern low land area where transmission is year-around (Zhou et
al., 2016). Malaria transmission become high from September to December following heavy
summer rainy season and lower transmission lasts from April to May following short rainy
season in most regions of Ethiopia. Also, prevalence and incidence of malaria vary depending on
variations in socio-demographic risk factors, including age and sex. The unstable transmission
patterns along with environmental modifications often make the country prone to cyclic
epidemics occurring every 5 to 8 years (FDREMH report, 2015, EPHIENMIS, 2016). For this
reason, to monitor and measure the impact of interventions, monitoring malaria burden and trend
in endemic areas is critical. However, such useful data remain scarce in several endemic areas of
Ethiopia, particularly in parts of SNNP Regional State.

1.2 Statement of the problem

According to World Malaria Report (2015) malaria is among the most frequently occurring and
distracting phenomenon that affects an average 26,400,000 (27% of total population) reside in
malaria high transmission areas ( >1 confirmed cases per 1000 population), 39,600,000 (41%) in
low (1 case per 1000 population) and 31,000,000 (32%) malaria free (0 cases per 1000
population) in 2014. Children, particularly under -five, including newborns and infants less
than12 months of age are one of the most exposed groups affected by malaria bearing 69% of
the above deaths point out that in high malaria transmission areas infants become
vulnerable to malaria at approximately 3 months of age. When immunity acquired from the
mother starts to go down and are becoming at increased risk of rapid disease progression,
severe malaria and death, severe anemia, hypoglycemia and cerebral malaria are features of
severe malaria which are particularly common in this age group (WHO, 2016).

A large peak in malaria case occurs during the major transmission season from September to
December, following the main rains June to August. The second transmission seasons in April
and May following short rains are a second but less pronounced peak occurs. Due to this
unstable and seasonal transmission pattern of malaria in the country, protective immunity of not

2
only children but the general population is low and all age groups are highly vulnerable to the
disease. Thus the public health burden of malaria is huge in Ethiopia (FMoH, 2015).

There were no studies conducted on the problem so as to investigate the prevalence of

malaria in five health facilities of Wondo Genet (Chuko, Kela, Wosha, Aruma and Babo) were
selected. Therefore, this study focuses on the retrospective assessment of malaria in health-
facilities of Wondo Genet for the last five years (2015-2019).This study was, therefore, designed
with the following objectives.

1.3 Objectives

1.3.1 General Objective

The general objective of the study was Facility-based retrospective study of malaria in Wondo
Genet, Sidama Region, Southern Ethiopia.

1.3.2 Specific Objectives

 To determine the prevalence and yearly pattern of malaria among patients who attended
in health-facilities of Wondo Genet between 2015 and 2019.
 To identify Plasmodium species involved in health-facilities of Wondo Genet.
 To identify sex and age distribution of malaria among patients attended in Health-
facilities of Wondo Genet

1.4 Significance of the study

It is obvious that the global malaria status is the sum total of each country status, and in turn the
country status is the sum total of its regional and local situations at each level. Accurate
assessments of the levels and time trends in malaria burden are crucial for the assessment of
progress towards goals and planning national health services and focusing future efforts
(R.E.Cibulskis et al., 2009)
Despite the aforementioned studies at different parts of the country, malaria situation with regard
to its trend, seasonal patterns, and distribution, particularly the case of the last five years‟ period,
remains unknown in the study area. Therefore, this study was aimed at determining the trend of
malaria occurrence in the Health-facilities of Wondo Genet over the last five years‟ period from

3
2015 to 2019 according to Ethiopian Calendar (E.C). The study provides scientific evidence that
would be an important data base of local, national, and global relevance in advancing current
knowledge on malaria situation. It is also useful to policy makers and program planners at each
level for assessing progress and focusing future efforts while providing evidence-driven public
health action in preventing and controlling malaria incidence.

1.5 Limitation of the study

The study was conducted in Wondo Genet Health facility. The scope of the study was delimited
to the Retrospective assessment of malaria in health-facilities of Wondo Genet. Due to time
and budget it did not include the prevalence and incidence of other than disease malaria.

4
2. REVIEW OF RELATED LITERATURE

2.1 Global burden of malaria

Malaria is one of the leading causes of morbidity and mortality in the world, with an estimated
3.3 billion people at risk of malaria. Malaria disease burden and spread can be assessed using
incidence or prevalence in human hosts. According to the latest world malaria report, released on
November 2015, there were 216 million cases of malaria in 2014, up from 211 million cases
in2013. In 2010, an estimate of 219 million cases of malaria was reported by the World Health
Organization and despite endless struggles to prevent its spread 660,000 people died from the
infection that year. However, the same year, a systematic review assessed the global malaria
mortality rate and revealed numbers exceeding over 1.2 million deaths, so the true
malaria burden might be underestimated (Murray, 2012).

In the world there are an estimated 3.3 billion people are at risk of being infected with
malaria and developing disease, and 1.2 billion are at high risk to acquire the disease. The burden is
heavies in the WHO African Region, where an estimated 90% of all malaria deaths occur, and in
children aged less than 5 years, which account for 78% of all deaths (WHO, 2014). It estimated
660,000deaths in 2011 directly attributed to malaria, approximately half of the world s population
being at risk of infection. The disease remains one of the major challenges for people's health
and livelihood around the world (WHO, 2015). Nearly half of the world s population is living under
the risk of malaria. As per the WHO estimates, 91 countries and territories had an ongoing
transmission of malaria in 2015 with 212 million identified cases and 429,000 deaths. Most
number of cases was reported from the African Region, followed by the Southeast Asia Region
(WHO, 2016). WHO recently launched the GTS for malaria, which aims to reduce the incidence
and mortality rates of malaria at least by 90% by 2030.

2.2 Malaria in Ethiopia

Malaria morbidity and mortality have been significantly decreased in Ethiopia in the past
decade. Ethiopia‟s fight against malaria started many years ago and transmission of this
infectious disease significantly decreased since 1959. However, malaria still remains a major
public health problem in Ethiopia. Ethiopia has a population of more than 100 million, and it is
estimated that ~ 68% of the population is at risk of the disease. Plasmodium falciparum and P.
vivax co-exist as major parasite species in Ethiopia (WHO, 2017). This epidemiologic feature
5
makes malaria control more complicated than in most African countries where P. vivax has low
or nil endemicity. Malaria transmission in Ethiopia occurs mainly at altitudes < 2000 m,
although endemic regions > 2000 m have been reported (FMoH, 2010). The levels of malaria
risk and transmission intensity, however, show marked seasonal, inter-annual and spatial
variability, with the exception of the southwestern international border low land area where
transmission is year-around (Zhou et al., 2016). In most regions of the country, the major
transmission season is from September to December, following the main rainy season from June
to September. There is a short transmission season from April to May following the short rainy
season in some regions.
Anopheles arabiensis is the predominant vector with An. pharoensis, An. coustani, An. funestus
and An. nili having a minor role in transmission. Generally, the diverse ecology of the country
supports a wide range of transmission intensities ranging from low-seasonal to high-perennial
transmission. For planning purposes and targeting of intervention strategies, the Federal Ministry
of Health (FMoH) of Ethiopia has stratified the country‟s malaria transmission burden using
„woreda‟ (district)-level transmission intensity according to annual parasite incidence per 1000
population (API) and elevation. Accordingly, four broad strata were identified by the mixed
criteria of the FMoH and World Health Organization (WHO) malaria free, low, moderate, and
high transmission. Plasmodium falciparum are endemic in many regions of the country.
Plasmodium malariae and P. ovale infection are uncommon and account for < 1% of confirmed
malaria cases (FMoH, 2010). Chloroquine (CQ) is currently the recommended first-line drug for
treatment of vivax malaria. In vivo monitoring of uncomplicated vivax malaria cases indicates
that the CQ is generally efficacious; however, treatment failures have been reported. The success
of malaria control efforts has largely depended on financial support from donor funds. In the past
decade Ethiopia has made significant strides in expanding coverage of key malaria interventions
throughout the country. Indoor residual spraying (IRS) using dichlorodi-phenyltrichloroethane
(DDT) was introduced in 1959 with the global malaria eradication campaign, and since then
different chemical insecticides have been used for malaria control (AIRS, 2016). Insecticide-
treated nets (ITN) were introduced in 1997 as an additional intervention. Chloroquine was the
first line treatment of all malaria species in Ethiopia before 1998. It was replaced by sulfa
doxine-pyrimethamine (SP) after 1998 for the treatment of uncomplicated P. falciparum due to
widespread decline in the efficacy of CQ. Parasites soon developed resistance to SP drugs.

6
Planning for scaling-up malaria prevention and control interventions started in 2003 with the
support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) (Kassa et
al.,2005). In 2004, the FMoH introduced artemisinin-based combination therapy (ACT) as the
first-line drug for treatment of P.falciparum malaria as well as rapid diagnostic tests (RDT) to
improve diagnosis and long-lasting insecticidal nets (LLINs) as a method of preventing
transmission of parasite from mosquitoes to people. Major scale-up began in 2005 with country-
wide distribution of RDTs, ACTs, LLINs and implementation of IRS.

2.3 Etiology of malaria Disease

A protozoan parasite belonging to the Genus Plasmodium causes malaria with five species: P.
falciparum, P. vivax, P. ovale, P. malaria, and P. knowlesi infect humans (Snow, 2005)
and is transmitted to humans through a bite from one of 40 species of female An. mosquitoes.
Plasmodium is transmitted by mosquitoes. Female mosquitoes belonging to the genus An. are
responsible for plasmodium transmission. Of over 430 An. species, only 30-40 transmit malaria
in nature and Anopheles gambiae complex is the most prominent plasmodium vector in Africa.
Themosquitoes which act as vector for this disease are female An. funestus, An. moucheti,
An. gambiae, An. arabiensis (Karl et al., 2014; WHO, 2015). Plasmodium falciparum is
responsible for almost all of the 1.7–2.5 million deaths worldwide caused by malaria and P.
falciparum remains the single most important threat to public health at a global scale,
accounting for more than 90% of the world‟s malaria mortality. A fifth Plasmodium
species named P. knowlesi, that previously was known to only infect macaques, has also newly
been shown to be able to infect humans (Baird, 2013). Although certain evidence advises
that P. falciparum coevolved with Homo sapiens, other observations show that it may have
emerged first in a non-human host such as the chimpanzee. Parasite was discovered in 1880 by
Alphonse Laveran (Mendis et al., 2009).

Africa had no malaria before and according to Nandi elders, malaria was introduced into Africa
by African soldiers who participated in First World War in 1918 and 1919 and after
coming back, 25% of the indigenous population got the disease (Lindsay and Martens,
1998). The relationship between humans and malaria may date back several million years
(Escalante et al., 1998). Among several Plasmodium species that cause human malaria naturally,

7
P. falciparum is by far the most severe and widespread. P. vivax malaria, traditionally
observed as a relatively benign form of the disease, is the next dominant species and can
also be a major cause of morbidity and mortality, in infants and young children. A recent
study from India reported P. vivax as a cause of acute respiratory distress syndrome which is
commonly associated to P. falciparum. P. ovale and P. malariae are relatively rare and are
usually not life-threatening (Cox-Singh, 2008).

2.4 Transmission and Life cycle

The disease is spread by the bite of infected female An. mosquitoes (Mockenhaupt et al., 2002),
which inoculates the parasites with its saliva at the time of biting. The disease is due to infection
with one of four species of the Plasmodium genus, which are obligate intracellular
protozoa (WHO, 2014). The cycle starts when an infected female An. mosquito bites an
individual and injects sporozoites, present in mosquito s salivary glands, into the host blood
stream during its blood meal. These sporozoites migrate to the liver where they mature and
multiply within hepatocytes. These forms are known as schizonts. This extra-erythrocytic stage
is asymptomatic. And usually lasts 6 days to 14 days, although sometimes it can last up to
several months or even years in the case of P. vivax or P. ovale. These two human
Plasmodium species can produce hypnozoites in the liver (Markus, 2011).

The life-cycle of vector -borne diseases like malaria is complex relative to that of many directly-
transmitted human. The malaria parasite life cycle involves two hosts. On the whole, directly
transmitted diseases require a threshold level and complexity of population agglomeration, and
are therefore relatively recent phenomena perhaps evolving within the last 10 millennia
(Anderson and May, 1990). Hypnozoites are a dormant form of the parasite, also called cryptic
form, which can stay in the liver for long periods of time and are the cause of the disease relapse.
After the liver stage, tens of thousands of merozoites will be released into the blood;
where they will invade and develop within erythrocytes. The blood stage of infection includes
asexual forms of the parasite that undergo repeated cycles of multiplication in erythrocytes,
causing parasite numbers to rise rapidly which is responsible for the symptoms of malaria.
Within the erythrocyte, the asexual forms of the parasite permits through different
sequential maturation stages: ring, trophozoite and schizont forms. In the end, the

8
erythrocyte ruptures and new merozoits are released and ready to infect new erythrocytes. Some
parasites will grow into the sexual forms, responsible for transmission, known as gametocytes.
The female and male gametocytes (macro-gametocyte and micro-gametocyte, respectively) will
be ingested by the mosquito vector during its feeding, and sexual reproduction occurs inside
the mosquito midget before the parasite is transmitted to another human host and the whole
cycle starts again (Greenwood et al., 2005).

The intensity of transmission depends on factors related to the parasite, the vector, the human
host, and the environment (WHO, 2014). The transmission intensity is highly sensitive to
environmental variations that affect the densities of these vectors and their ability to transmit the
infection. Temperature influences the length of larval development, mosquito survival, and
parasite development. Elevated temperatures accelerate the development rate of both the
mosquito larvae and of the Plasmodium parasites (Paaijimanset et al., 2009). Variations in
transmission intensity have been observed within very small localities due to geographical (the
geographical distribution of these species varies; P. vivax infection is rare in Africa but Negash
et al., 2005; Ghebreyesus et al., 2006).

2.5 Signs and symptoms of malaria

The symptoms include fever and flu-like illnesses such as shaking, chills, headache,
muscle aches, tiredness and general feeling of discomfort. Nausea, vomiting and diarrhea
may also happen. Malaria can cause anemia and jaundice because of harm of red blood cells. As
these symptoms are so general, malaria is often misdiagnosed clinically. Most malaria signs
and symptoms begin 1-4 weeks after the infective mosquito bite. Inadequately taken
malaria prophylactic medicines, however, may elongate the incubation period. The symptoms of
malaria are and the asexual (blood- borne) stage of the parasite are similar (Newton et al., 1998).
The first symptom of malaria is viral illness which leads to following symptoms:- Abdominal
discomfort, Headache, Joint aches, Muscle aches, Abdominal discomfort, Vomiting,
Lethargy, Anorexia. According to WHO first symptoms of malaria are fever, headache, chills
and vomiting that are not specific to malaria. If not preserved within 24 hours, malaria due
to P. falciparum can progress to severe illness that can lead to death (WHO, 2014).

Asymptomatic infections can occur in endemic area because of partial immunity development
(WHO, 2010). Children with severe malaria can grow one or more of the following

9
symptoms: severe anemia, respiratory distress due to metabolic acidosis, or cerebral malaria.
In general, symptoms include periodic chills and fevers, malaise, lethargy, headache, nausea,
abdominal pain and sometimes vomiting and diarrhea. P. falciparum is the major strain that
can cause severe disease such as severe anemia, cerebral malaria, pulmonary edema,
acute respiratory distress syndrome and renal failure, and thus is the strain causing most deaths
(White et al., 2013).

2.6 Diagnosis and treatment

Malaria diagnosis is usually made by examining a peripheral blood slide for the presence of
parasites. Malaria microscopy uses a blood film test (WHO, 2010). While a single positive blood
test result may evidence the existence of malaria, a single negative test is insufficient to exclude
it. If malaria is suspected at least three negative blood film tests can be done to rule out it. In
skilled hands, this is still the most sensitive means of detecting infection Rapid
Diagnostic Tastes (RDTs) are also employed. RDTs, by which parasite antigens are detected in
a drop of blood applied to a test strip, have become more widely available in recent years, but
their cost remains prohibitive in many countries. The currently available RDTs detect one or
more of the parasite anti-gens, HRP2 lactate dehydrogenase and aldose and are usually
specific for P. falciparum infections or mixed infections containing P. falciparum. Malaria
indicative signs and symptoms are important for its diagnosis. In most SSA, there is insufficient
staff or resources available to perform blood tests whether by microscopy or by RDTs – on
every patient with suspected malaria. In much of the world where malaria is endemic,
asymptomatic infection is common and the presence of parasites in the blood does not equate to
disease (Baired, 2013). Malaria is treated with certain types of prescription medicines
depending on the Plasmodium species detected, level of disease severity, patient age, pregnancy
status and the overall malaria control policy of the country in question. If untreated, P.
falciparum malaria may lead to death particularly in under-five children within hours of the
onset of signs and symptoms. Severe malaria during pregnancy can also result in failure,
low-birth weight infants, developmental disabilities and other related later difficulties (Clark,
1915; Cot and Deloron, 2003).

Malaria control is mostly based on prompt case detection and treatment in addition to
vector control measures. Treatment of Malaria most available anti-malarial drugs were

10
designed to target the symptomatic blood stages and thus act only against the sexual
blood forms (Baired, 2013). Chloroquine succeeds as the first-line treatment for P. vivax
infections in Ethiopia (including other SSA countries) (Mekonnen et al., 2014). Drugs are used
to prevent (chemoprop hylaxis) and treat infection in individuals. While many new anti-
malarial drugs have been developed in the last 20 years (mefloquine, halofantrine, artmisinin,
malarone, atovaquone and proguanil, co-artemether) (Mohammed et al., 2015). Treatment of an
individual diagnosed with P. falciparum malaria is of great concern because contrary to the other
species, it can be rapidly fatal (White et al., 2013). Individuals can protect themselves against
malaria by wearing protective clothing and using insect repellents and bed nets (Zerihun et
al., 2007). ACT, distribution of LLINs, and IRS are important in the reduction of malaria
burdens (WHO, 2015; Griffin et al., 2010).

11
3. MATERIALS AND METHODS

3.1 Description of the study Area

The study was conducted in Wondo Genet town, which are about 270km to the south of Addis
Ababa and 24km to the east of Hawassa city. Wondo Genet is bordered with Oromia in the west,
Melga Woreda in the east, Habella Tula Kifle Ketema in the south and Oromia Region in the
north. The result of analysis of data from National Meteorogical Service (NMSA) from Hawassa
showed that the range of mean monthly minimum and maximum temperature of the study area
are 10.2 and 30.1 0c in the month of December and February respectively. The agro ecology of
the woreda has 23% humid and 77% sub-humid tropical climate and receives a mean annual
rainfall of 1163mm per year. Short rain season is between March and May and accounting for
28% and long rain season is between July and October accounting for more than 50% of the total
annual rainfall (Tuasha et al 2019).

The Town has an average elevation of 1880 meters above sea level. The area is known for its
cash crops including sugarcane and khat (Catha edulis), enset (Enset ventricosum) and maize
(Zea mays) are major food crops in the area. The wondogenet forestry plantation is prominent in
the area with several small-scale irrigation canals that irrigate various crop farms including the
above. The area is known for its malaria endemicity.

12
Figure -1: Map of study area (source: Tuasha et al 2019 BMC Infectious Diseases)

13
3.2 Study Design

A retrospective design was employed using data from health-facilities of Wondo Genet. This was
done by reviewing past five-year (2015 - 2019) malaria morbidity records of the Health Centers.

3.3 Data Collection

Residents of Wondo Genet district who visited Wondo Genet Health Center complaining febrile
illness during the study period and parasitologically examined for malaria were considered.
Socio-demographic and laboratory data were collected from patients‟ registration book. In this
health center, the staining technique and blood film examination for malaria parasite detection
are conducted according to a standard operating procedure (SOP) adopted from WHO protocol
(WHO 2010).

3.4 Data Analysis

Data was entered into Microsoft Office Excel and analyzed using Statistical Package for Social
Sciences (SPSS) version 20. Chi-squares (X2) test was used to test differences in retrospective
malaria prevalence between years, sexes, age groups and seasons. P<0.05 was considered
statistically significant.

3.5 Ethical Considerations

The study was approved by the Addis Ababa University College of Natural and Computational
Sciences Institutional Review Board (IRB/46/2020). After discussing the purpose and method of
the study, written permission was sought from the head of Wondo Genet Health facility.

14
4. RESULTS

4.1. Annual Trends of Malaria Prevalence

Within the last five-year (2015 - 2019) a total of 15218 blood films were requested for malaria
diagnosis from the five Health Facilities of Wondo Genet and 3530(23.20%) were
microscopically confirmed as malaria cases. There was a decreasing trend of malaria with the
maximum 2885(47.16%) confirmed malaria cases in 2015 and the minimum 47(2.5%) in 2019
(Table 1).

P. falciparum and P. vivax were the major causative agents for malaria infection in the study
area. Both species were reported in the last five years with P. vivax and P. falciparum showed
nearly similar occurrence. On the whole 1770 (50.14%) and 1760 (49.86%) of the cases were
attributed to P.vivax and P. falciparum respectively. The difference was not statistically
significant (P>0.05). There were higher P. vivax monoinfections in 2016(54.98) and
2019(51.06%) than P. faciparum (45.01% and 48.94%) respectively), and the reverse was
observed in 2015 and 2017. It appeared that there was a negligible trend shift from P. vivax to P.
falciparum and vice versa and the distribution was more or less stable.

Table 1 Slide-confirmed annual malaria cases and distribution of Plasmodium species in Wondo
Genet (2015 - 2019)
Year Examined Positive, n(%) P. falciparum, n(%) P. vivax, n(%) P-value
2015 6118 2885(47.2) 1452(50.3) 1433(49.7) 0.054
2016 3110 391(12.6) 176(45.0) 215(54.9)
2017 2113 126(5.9) 69(54.8) 57(45.2)
2018 1997 81(4.1) 40(49.4) 41(50.6)
2019 1880 47(2.5) 23(48.9) 24(51.1)
Total 15218 3530(23.2) 1760(49.9) 1770(50.1)

15
 P. falciparum
P. vivax

Figure-2: Annual malaria cases and distribution of Plasmodium species in Wondo Genet (2015 -
2019)

4. 2. Prevalence of malaria with respect to sex and age groups

In terms of sex, 8027 of the total examined patients were males and 7191 females. Out of the
malaria slide-positive individuals, 1856(52.6%) were males and 1674(47.4%) females (Table 2).
Males were more affected than females although the difference was not statistically significant.
Table-2: Sex distribution of malaria cases by sex at Wondo Genet Health Center, Wondo Genet,
South Ethiopia (2015 - 2019)

Year Examined Positive n (%) Male n (%) Female n (%) P-value

2015 6118 2885 (47.2) 1536 (53.2) 1349 (46.8) 0.102

2016 3110 391 (12.6) 198 (50.6) 193 (49.4)

2017 2113 126 (5.9) 50 (39.7) 76 (60.3)

2018 1997 81 (4.0) 44 (54.3) 37 (45.7)

2019 1880 47 (2.5) 28 (59.6) 19 (40.4)

Total 15218 3530 (23.3) 1856 (52.6) 1674 (47.4)

16
Regarding distribution of malaria prevalence by age groups, out of 3530 total positive tests,
27.7% of the positive tests were in the age group of <5, 32% of the positive tests were in the age
group of 5-14 and 40.3% positive tests were in the age group of >14. The data showed that the
highest malaria prevalence was observed in the age groups of 15 and above 15 years (Table 3).
However, the prevalence of malaria among age groups was not statistically significant (P>0.05).

Table 3 Distribution of malaria slide-confirmed cases in Wondo Genet Health Center in Wondo
Genet (2015 - 2019)
Age Examined Positive n (%) P. falciparum n P.Vivax n (%) P. Value
(%)

<5 3462 976 (27.7) 492 (50.4) 484 (49.6) 0.078

5-14 4651 1131 (32.0) 565 (49.96) 566 (50.04)

>14 7101 1423 (40.3) 701 (49.26) 722 (50.74)

Total 15218 3530 (100) 1760 (49.86) 1770 (50.14)

17
4.3. Seasonal variation of malaria prevalence at Wondo Genet Health Center (2015-2019)
A seasonal distribution of malaria cases is indicated (Table 4). The highest malaria prevalence
599(16.9%) was observed during August followed by June 546(15.5%) and September
503(14.3%). However, no malaria cases were recorded in the months of November, December,
April and May. The occurrence of P. vivax was higher than P. falciparum in each month except
in October, January and June.

Table 4 Seasonal variation of malaria prevalence in Wondo Genet, south Ethiopia (2015 - 2019)
Month Examined Positive n (%) P. falciparium n P. vivax n p-value
(%) (%)

September 1234 503 (14.25) 244 (48.5) 259 (51.5) 0.038

October 1336 488 (13.82) 245 (50.2) 243 (49.8)

November 915 0 0 0

December 921 0 0 0

January 890 205 (5.8) 107 (52.2) 98 (47.8)

February 1129 414 (11.73) 206 (49.76) 208 (50.24)

March 1269 412 (11.67) 204 (49.51) 208 (50.49)

April 1464 0 0 0

May 617 0 0 0

June 2489 546 (15.47) 282 (51.65) 264 (48.35)

July 683 363 (10.28) 177 (48.76) 186 (51.24)

August 2271 599 (16.97) 299 (49.92) 300 (50.08)

Total 15218 3530 (100) 1760 (49.86) 1770 (50.14)

18
4.4 Discussion

In this study, a total of 3530 (23.20%) malaria prevalence among patients were reported in the
last five years, period from 2015 to 2019. This was lower than the study conducted Abeshge
district, Walga Health Center (Yimer et al., 2015) in which the overall prevalence of malaria was
(33.8%). My finding also showed that the highest number of malaria slide- positives was in 2015
and then after declining trend continued with the lowest number of cases in 2019. This is because
of increasing awareness of the community about the transmission and prevention methods of
malaria. If this trend of declining of malaria prevalence continued, it will be totally controlled in
the study area in the next two decades (2030).
From the result of the study the higher plasmodium species detected was P. vivax (50.14%)
followed by P. falciparum (49.86%). This result is different from the study conducted in Kola
Diba Health center in which P. vivax accounted 75% and P. falciparum accounted 25% (Alemu
et al., 2013). But other studies reported that the most prevalent species was P. falciparum. The
study conducted in Metema Hospital reported that P. falciparum accounted 90.7% and P. vivax
9.3% and mixed infection 0.3% (Getachew et al., 2013). However, this study contradicts with the
study conducted similarly, a research conducted in Arsi Negele in which the prevalence of P.
falciparum and P. vivax was 19.8 and 74% respectively and mixed infection was 6.2% (Mengistu
and Solomon, 2014). The nationwide picture, in Ethiopia which indicates that P. faliciparum
and P. vivax are the two predominant parasites distributed in the country and accounting for 60%
and 40% of malaria cases respectively (FMOH, 2012).This might be observed variation on
climate in study area.
The data showed that males (52.6%) were more infected than females (47.4%) but without any
significant statistical difference. This is in line with other studies in Ethiopia (Getachew et al.,
2013). According to the study conducted at Kola Diba Health Center males were more affected
than females. The infection rates among males were 52.6% and females were 47.3%. The reason
why malaria affected more males might be due to the fact that males engaged in activities outside
their residence area, migration which make them more prone to infective mosquito bites as
compared to female counter parts which are mostly at home and are not exposed counter parts
which are mostly at home and are not exposed to malaria areas and protected from such infects
bites.

19
Regarding the age groups, malaria infection was recorded from all age groups in the study area.
However, the rate of infection was high in the age groups 15 and above years old followed by 5-
14 years old.
In the study area, seasonal variation of malaria prevalence differs in each month of the year. The
highest prevalence of malaria cases was observed during June, August and September and there
was no any malaria cases observed during November, December, April and May This might be
due to shortage of moister or in the study area after October the rain season become highly
decrease. This is not in concurrent with other studies done in Kola Diba Health Center in which
malaria transmission peaks from September to November (Getachew et al., 2013).

20
5. CONCLUSIONS AND RECOMMENDATIONS

5.1. Conclusions

The following conclusions were drawn based on the findings of the present study.

 There was a decreasing trend of malaria within the last five years with the maximum
2885(47.2%) confirmed cases in 2015 and the minimum 47(2.5%) in 2019.
 Both P. falciparum and P. vivax were reported. Overall, P. vivax was slightly higher, and
no mixed-infection cases.
 Males (52.6%) were more affected than females (47.4%) although the difference was not
statistically significant.
 The highest malaria prevalence (40.3%) was in the 15 years and above and the lowest
(27.7%) in under-5.
 The distribution of malaria showed seasonality with the highest prevalence in June,
August and March.

5.2 Recommendations

Based on the findings of the study, the following are recommended to minimize malaria burden
in Wondo Genet.

 Although the study showed a decreasing trend, malaria remains a public health problem
in Wondo Genet and increasing control efforts is necessary to achieve better.

 Seasonal variations require more focused attention to better control malaria

transmissions and potential outbreaks.

 Community-based studies are recommended for better understanding of malaria

transmission dynamic including delineation of risk factors in the study area.

21
REFERENCES
Abebe TN (2014). Compiled body of works in field epidemiology, MPH Thesis, School of
Public health, Ethiopia field epidemiology training program, Addis Ababa University,
Addis Ababa, Ethiopia

Alemu A, Fuehrer HP, Getnet G, Tessema B, Noed H (2013). P. ovale curtisi and P. ovale
wallikeri in North-West Ethiopia. Malar J; 12:346.

Aregawi M, Lynch M, Bekele W, Kebede H, Jima D, Taffese HS, Yenehun AM, Lilay
A, Williams R, Thomson M, Nafo-Traore F, Admasu K, Gebreyesus AT,
Coosemans M (2014). Time series analysis of trends in malaria cases and deaths at
hospitals and the effect of antimalarial interventions, 2001-2011,Ethiopia.

Baird JK (2013). Evidence and implications of mortality associated with acute P. vivax malaria.
Clin Microbiol Rev.; 26:36–57.

Bamaga OA, Mahdy MA1, Mahmud R, Lim YA (2014) Malaria in Hadhramout, a southeast
province of Yemen: prevalence, risk factors, knowledge, attitude and practices (KAPs).
Parasite Vectors; 7: 351.

Clark HC (1915). The diagnostic value of the placental blood film in aestivo-autumnal malar. J
Exp Med; 22: 427–45.

Cot, Deloron (2003). Malaria prevention strategies: Pregnancy-Associated Malaria (PAM). Br

Med Bull 67(1):137-48.

Cox-Singh J (2008). P. knowlesi malaria in humans is widely distributed and potentially

life threatening. Clin. Infect. Dis. 46: 165-171.

Eacalant. A. A, Freeland DE, Collins WE and Lal AA (1998). The evolution of primate malaria
parasites based on the gene encoding cytochrome-b from the linear mitochondrial
genome. Proceedings of the National Academy of Sciences of the United States of
America 95:8124-8129.

FMoH (2015). HSDP IV annual performance report 2014/2015. Addis Ababa: Ministry of
Health.

22
FMoH (2000). Malaria control profile. Ministry of Health, Addis Ababa, Ethiopia, pp1-10

FMoH, (2012), National Strategic Plan for Malaria Prevention, Control and Elimination in
Ethiopia: 2011–2015, Addis Ababa, Ethiopia

Gebremariam N (1988). The ecology of health and disease in Ethiopia in Malaria. Edited by
Kloos H, Zein AZ. Boul Westview Press; 136-150.

Getachew, F., Abiyu W, Alemtegna G, Ali A, Tarekegn H, Yenus A, Belay T, Yitayih W, and
Abebe A (2013). Prevalence of malaria from Blood Smears Examination: A seven-year
Retrospective study from Metema Hospital, North West Ethiopia. Malaria Research and
Treatment; 2013, article ID 704730

Gething PW, Patil AP, Smith DL (2011). A new world malaria map: P. falciparum endemicity in
Malar Edited; 556-576.

Ghebreyesus TA, Derressa Witten KH, Getachew A, Seboxa T (2006). The epidemiology and
ecology of health and disease in Ethiopia, In Malar Edited, 556-576

Greenwood BM., Bojang K,, Whitty CJ and Targett GT (2005).JCI Malaria progress, perils
and prospects for eradication, Malar Lancet; 365 (9469), 1487–98.

Griffin JT, Hollingsworth TD, Okell LC, Churcher TS, White M, Hinsley W,Bousema T,
Drakeley CJ, Ferguson NM, Basáñez MG, Ghani AC (2010). Reducing P. falciparum
malaria transmission in Africa: a model-based evaluation of intervention strategies; Med,
7:e1000324.

Kassa M, Sileshi M, Mohammed H, Taye G, Asfaw M. (2005) Development of resistance by

Plasmodium falciparum to sulfadoxine/pyrimethamine in Amhara region, Northwestern
Ethiopia, Ethiop Med J.;43:181–7.

Khattak AA, Venkatesan M, Nadeem MF, Satti HS, Yaqoob A, (2013). Prevalence and
distribution of human Plasmodium infection in Pakistan. Malar J, 12: 297

Lindsay SW, Martens WJM (1998). Malaria in the African highlands: Past, present and future.
Bull World Health Organ; 76(1):33–45.

23
May RM and Anderson RM (1990). Parasite-host co-evolution. Review [50 refs]. Para 100
Supp: S89-101.

Mekonnen, SK, Aseffa A, Berhe N, Teklehaymanot T, Clouse RM., Gebru T, Medhin G,

Velavan TP(2014). Return of chloroquine-sensitive Plasmodium falciparum parasites
and emergence of chloroquine-resistant Plasmodium vivax in Ethiopia. Malar. J. 13: 244.

Mengistu, H. and Solomon, G. (2014).Trend Analysis of Malaria Prevalence in Arsi Negelle

Health Center, Southern Ethiopia, Acad. J. vol.7(1), 1-6

MI. Africa IRS (AIRS) (2016) Project Indoor Residual Spraying (IRS 2) Task Order Six.
Ethiopia 2016 End of spray report. Bethesda, MD: Abt Associates Inc.

Ministry of Health (2010). National strategic plan for malaria prevention, control and elimination
in Ethiopia,2011–2015. Addi Ababa: Ministry of Health of Ethiopia;
http://www.nationalplanningcycles.org/sites/default/files/country_docs/Ethiopia/ethiopia
_malaria_national_strategic_plan_2011-2015_130810.pdf. Accessed 21 July 2021.

Mockenhaupt FB, Ulmen U, von Gaertner C, Bedu-Addo G, Bienzle U (2002). Diagnosis

of placental malaria. J C lin Microbiol; 40:306–malariology. 4th ed. London: Arnold;
2002. p. 85–106.

Mohammed H, Tedla M, Meseret B, Moges K, Daddi A, Mekonnen T, Adugna W, Tesfaye M,

Amha K (2015). Genetic diversity of Plasmodium falciparum isolates based on MSP-1
and MSP-2 genes from Kolla-Shele area, Arbaminch Zuria District, southwest Ethiopia.
Malar J 14: 73.

Murray CJ. (2012). Global malaria mortality between 1980 and 2010: systematic analysis.
Lancet 379: 413-431.

Nega D., Assefa A., Mohamed H., Solomon H., Woyessa A., Assefa Y., Kebede A., Kassa M.
(2016). Therapeutic efficacy of artemether-lumefantrine (Coartem) in treating
uncomplicated P. falciparum Malaria in Methahara, Estern Ethiopia. Reg cli sty. PLoS
One 11(4): e0154618

24
Negash K., Kebede A., Medhin A., Argaw D., Babaniyi O., Guintran JO., Delacollette C.
(2005). Malaria epidemics in the highlands of Ethiopia. East Africa Med J, 82:186-192.

Newton CR., Taylor TE., Whitten RO. (1998). Patophysiology of fatal falciparum malaria in
Africa children. AM, J. Trop.med Hyg.58 (5), 673-683.

Paaijmans KP., Read AF., Thomas MB. (2009). Understanding the link between malaria risk and
climate. Proc. Natl. Acad. Sci. USA, 106: 13844.

R. E. Cibulskis, M. Aregawi, R.Williams, M. Otten, and C. Dye, “Worldwide incidence of

malaria in 2009: estimates, time trends, and a critique of methods,” PLoS Medicine, 8,
no.12,

Sinka ME, Rubio-Palis Y, Manguin S, Patil AP, Temperley WH, Gething PW, Van Boeckel T,
Kabaria CW, Harbach RE, Hay SI 2010. The dominant Anopheles vectors of human
malaria in the Americas: occurrence data, distribution maps and bionomic pré-cis.
Parasit Vectors 3: 72.

Snow RW., Guerra CA., Noor AM. (2005). The global distribution of clinical episodes of P.
falciparum malaria.Natyre.; 434:214-217

Tausha N, Hailemeskel E, Erko B, Beyene P (2019). BMC Infectious Diseases volume 19,8-10.

White NJ, Pukrittayakamee S, Hien T, Faiz MA, Mokuolu O, Dondorp AM (2013).

Malar. Lancet, 6736 (13).85

WHO - World Health Organization 2013. WHO Global Malaria Programme. World Malaria
Report 2013, WHO, Geneva, 255 pp

WHO. (2014). World Malaria Report 2016, Geneva

WHO. (2016). World Malaria Report 2016, Geneva

World Health Organization. World Malaria Report 2017. http://www.who.

int/malaria/publications/world-malaria-report-2016/report/en/ .Accessed 21 July 2021.

25
Yimer F., Animut A., Erko B., Mamo H. (2015). Past five-year trend, current prevalence
and household knowledge, attitude and practice of malaria in Abeshge, South central
Ethiopia, Malar J. 14:230

Zerihun, Afework TH and Kolaczinski JH. (2007). Potential for integrated control of neglected
tropical diseases in Ethiopia. Trans Roy Sci Trop Med and Hyg, 102: 213-214.

Zhou G, Yewhalaw D, Lo E, Zhong D, Wang X, Degefa T. (2016). Analysis of asymptomatic

and clinical malaria in urban and suburban settings of south western Ethiopia in the
context of sustaining malaria control and approaching elimination. Malar J; 15:250

Zhou G., Afrane YA., Malla S., Githeko AK., Yan G. (2015). Active case surveillance, passive
case surveillance and asymptomatic malaria parasite screening, western Kenya. Malar
J.; 14:41

26
DECLARATION

I hereby declare that this M.Sc. thesis is my original work and has not been presented for a
degree in any other university and that all sources of materials used for this thesis have been
duly acknowledged.
Name: Kassahun Lemma
Signature:
This M.Sc. thesis has been submitted for examination with our approval as thesis advisors.
Major advisor-Name:
Signature:

27