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Background In Ethiopia, malaria cases are declining as a result of proven interventions, and in 2017 the country launched a malaria elimination strategy in targeted settings. Accurate malaria diagnosis and prompt treatment are the key components of the strategy to prevent morbidity and stop the continuation of transmission. However, the quality of microscopic diagnosis in general is deteriorating as malaria burden declines. This study was carried out to evaluate the competency of microscopists and the performance of health facilities on malaria microscopic diagnosis. Methods A cross-sectional study was conducted from 1 August to 30 September, 2019 in 9 regional states and one city administration. A standard checklist was used for on-site evaluation, archived patient slides were re-checked and proficiency of microscopists was tested using a WHO-certified set of slides from the national slide bank at the Ethiopian Public Health Institute (EPHI). The strength of agreement, sensitivity, specificity, and positive and negative predictive values were calculated. Results In this study, 102 health facilities (84 health centres and 18 hospitals) were included, from which 202 laboratory professionals participated. In slide re-checking, moderate agreement (agreement (A): 76.0%; Kappa (K): 0.41) was observed between experts and microscopists on malaria detection in all health facilities. The sensitivity and specificity of routine slide reading and the re-checking results were 78.1 and 80.7%, respectively. Likewise, positive predictive value of 65.1% and negative predictive value of 88.8% were scored in the routine diagnosis. By panel testing, a substantial overall agreement (A: 91.8%; K: 0.79) was observed between microscopists and experts in detecting malaria parasites. The sensitivity and specificity in the detection of malaria parasites was 92.7 and 89.1%, respectively. In identifying species, a slight agreement (A: 57%; K: 0.18) was observed between microscopists and experts. Conclusion The study found significant false positive and false negative results in routine microscopy on slide re-checking of Plasmodium parasites. Moreover, reduced grade in parasite species identification was reported on the panel tests. Implementing comprehensive malaria microscopy mentorship, in-service training and supportive supervision are key strategies to improve the overall performance of health facilities in malaria microscopy.

Background Anopheles mosquitoes are of great importance to human health. A number of studies have shown that midgut and salivary gland microflora have an impact on malaria parasite burden through colonization mechanisms, involving either direct Plasmodium microbiota interaction or bacterial-mediated induction of mosquito immune response. The objective of this study was to isolate and identify the microflora from the midgut and salivary glands of Anopheles species. Methods A total of 20 pools (ten per pool) from insectary-reared and 56 pools (five per pool) of field-collected Anopheles mosquitoes were anesthetized by chloroform and dissected. 70% of ethanol was used for surface sterilization of mosquitoes and laboratory equipment, followed by rinsing Anopheles mosquitoes four times with 1X PBS. Each pool of dissected midgut and salivary gland sample was transferred in 1X PBS and squashed, incubated in the water bath and enriched in tryptic soya broth for 24 h at 35 ± 2 °C. As a control, the PBS solutions used to rinse the mosquitoes were also incubated in tryptic soya broth in the same conditions as the sample. After enrichment, a loopful of each sample was taken and inoculated on Blood, Chocolate, MacConkey, and Sabouraud Dextrose agar. Finally, the microbiota was isolated by colony characteristics, biochemical tests, and automated VITEK 2 Compact Analyzer. Results From all field and laboratory mosquitoes, Pseudomonas was found to be the dominant microbiota identified from all species of Anopheles mosquitoes. Acinetobacter and Klebsiellapneumonia and other families of gram-positive and gram-negative bacteria were identified. Conclusions A number of bacteria were isolated and identified. This is the first report on isolation and identification of microbiota from midgut and salivary glands of Anopheles species in Ethiopia. It can be used as a baseline for studying the relationship between microbiota and mosquitoes, and for the development of a new malaria biological control.

Background Encouraged by the previous success in malaria control and prevention strategies, the Ethiopian ministry of health launched malaria elimination with a stepwise approach by primarily targeting the low-transmission Districts and their adjacent areas/zones in order to shrink the country’s malaria map progressively. Hence, this community survey was conducted to establish baseline malaria information at the preliminary phase of elimination at targeted settings. Methods A community-based cross-sectional survey was conducted at 20 malaria-elimination targeted Districts selected from five Regional states and one city administration in Ethiopia. The GPS-enabled smartphones programmed with Open Data Kit were used to enumerate 9326 study households and collect data from 29,993 residents. CareStart™ Malaria PAN (pLDH) Rapid Diagnostic Tests (RDTs) were used for blood testing at the field level. Armpit digital thermometers were used to measure axillary temperature. Result Overall malaria prevalence by RDTs was 1.17% (339/28973). The prevalence at District levels ranged from 0.0 to 4.7%. The proportion of symptomatic cases (axillary temperature > 37.5oc) in the survey was 9.2% (2760/29993). Among the 2510 symptomatic individuals tested with RDTs, only 3.35% (84/2510) were malaria positive. The 75.2% (255/339) of all malaria positives were asymptomatic. Of the total asymptomatic malaria cases, 10.2% (26/255) were under-five children and 89.8% (229/255) were above 5 years of age. Conclusion The study shows a decrease in malaria prevalence compared to the reports of previous malaria indicator surveys in the country. The finding can be used as a baseline for measuring the achievement of ongoing malaria elimination efforts. Particularly, the high prevalence of asymptomatic individuals (0.88%) in these transmission settings indicates there may be sustaining hidden transmission. Therefore, active case detection with more sensitive diagnostic techniques is suggested to know more real magnitude of residual malaria in the elimination-targeted areas.

Background An accurate understanding of the geographical distributions of both soil-transmitted helminths (STHs; Ascaris lumbricoides, Trichuris trichiura, and the hookworms Necator americanus and Ancylostoma duodenale) and schistosomes (SCH; Schistosoma mansoni and S. haematobium) is pivotal to be able to effectively design and implement mass drug administration (MDA) programmes. The objective of this study was to provide up-to-date data on the distribution of both STH and SCH in Ethiopia to inform the design of the national control program and to be able to efficiently achieve the 75% MDA coverage target set by the WHO. Methods Between 2013 and 2015, we assessed the distributions of STH and SCH infections in a nationwide survey covering 153,238 school-aged children (aged 5–15 years), from 625 woredas (districts), representing all nine Regional States and two City Administrations of Ethiopia. Nationwide disease maps were developed at the woreda level to enable recommendations on the design of the national MDA programme. Results The prevalence of any STH infection across the study population was 21.7%, with A. lumbricoides (12.8%) being the most prevalent STH, followed by hookworms (7.6%) and T. trichiura (5.9%). The prevalence for any SCH was 4.0% in areas where both SCH species were evaluated. Schistosoma mansoni was the most prevalent SCH (3.5 vs 0.3%). STHs were more prevalent in southwest Ethiopia, whereas SCH was found mostly in the west and northeast of the country. The prevalence of moderate-to-heavy intensity infections was 2.0% for STHs and 1.6% for SCH. For STH, a total of 251 woredas were classified as moderately (n = 178) or highly endemic (n = 73), and therefore qualify for an annual and biannual MDA program, respectively. For SCH, 67 woredas were classified as endemic and 8 as highly endemic, and hence they require every two years and annual MDA programme, respectively. Conclusions The results confirm that Ethiopia is endemic for both STHs and SCH, posing a significant public health problem. Following the WHO recommendations on mass drug administration, 18 and 14 million school-aged children are in need of MDA for STHs and SCH, respectively, based on the number of SACs that live on the eligible geographical areas.

Background Onchocerciasis transmission across international borders is not uncommon, yet a coordinated cross border stops mass drug administration (MDA) decision has not been documented. Methods/Principle findings The Galabat-Metema focus involves neighboring districts on the border between Sudan and Ethiopia. Mass drug administration (MDA) was provided once and subsequently twice per year in this focus, with twice-per-year beginning in Ethiopia’s Metema subfocus in 2016 and in the Sudan’s Galabat subfocus in 2008. Ov16 ELISA-based serosurveys were conducted in 6072 children under 10 years of age in the Metema subfocus in 2014, and 3931 in the Galabat in 2015. Between 2014 and 2016, a total of 27,583 vector Simulium damnosum flies from Metema and 9,148 flies from Galabat were tested by pool screen PCR for Onchocerca volvulus O-150 DNA. Only 8 children were Ov16 seropositive (all in the Metema subfocus); all were negative by skin snip PCR. The upper limit of the 95% confidence interval (UCL) for Ov16 seropositive was, Author summary Onchocerciasis is a vector-borne tropical disease caused by the parasitc worm, Onchocerca volvulus. The vector is Simulium flies that breed in fast flowing rivers and streams. The infection can cause skin disease and loss of vision, giving risk to the common name of ‘river blindness’ for the condition. Ivermectin (Mectizan) mass drug administration (MDA) given at high coverage for many years can interrupt transmission such that MDA can eventually be stopped. The present paper provides highlights of onchocerciasis transmission interruption in the first known coordinated international cross border focus with ivermectin MDA program in Africa, where 99% of the global onchocerciasis burden exists. This focus known as Galabat-Metema is shared between Ethiopia and Sudan, both of which have established a nationwide policy for elimination of onchocerciasis. The paper provides the history of MDA in the border area and the results leading a coordinated end to MDA in the focus in 2017.

Background The goal of the global lymphatic filariasis (LF) program is to eliminate the disease as a public health problem by the year 2020. The WHO mapping protocol that is used to identify endemic areas in need of mass drug administration (MDA) uses convenience-based sampling. This rapid mapping has allowed the global program to dramatically scale up treatment, but as the program approaches its elimination goal, it is important to ensure that all endemic areas have been identified and have received MDA. In low transmission settings, the WHO mapping protocol for LF mapping has several limitations. To correctly identify the LF endemicity of woredas, a new confirmatory mapping tool was developed to test older school children for circulating filarial antigen (CFA) in settings where it is uncertain. Ethiopia is the first country to implement this new tool. In this paper, we present the Ethiopian experience of implementing the new confirmatory mapping tool and discuss the implications of the results for the LF program in Ethiopia and globally. Methods Confirmatory LF mapping was conducted in 1,191 schools in 45 woredas, the implementation unit in Ethiopia, in the regions of Tigray, Amhara, Oromia, SNNP, Afar and Harari, where the results of previous mapping for LF using the current WHO protocol indicated that LF endemicity was uncertain. Within each woreda schools were selected using either cluster or systematic sampling. From selected schools, a total of 18,254 children were tested for circulating filarial antigen (CFA) using the immuno-chromatographic test (ICT). Results Of the 18,254 children in 45 woredas who participated in the survey, 28 (0.16%) in 9 woredas tested CFA positive. According to the confirmatory mapping threshold, which is ≥2% CFA in children 9–14 years of age, only 3 woredas out of the total 45 had more CFA positive results than the threshold and thus were confirmed to be endemic; the remaining 42 woredas were declared non-endemic. These results drastically decreased the estimated total population living in LF-endemic woredas in Ethiopia and in need of MDA by 49.1%, from 11,580,010 to 5,893,309. Conclusion This study demonstrated that the new confirmatory mapping tool for LF can benefit national LF programs by generating information that not only can confirm where LF is endemic, but also can save time and resources by preventing MDA where there is no evidence of ongoing LF transmission., Author summary Lymphatic filariasis (LF) is a mosquito-borne parasitic disease, caused by 3 nematode parasites, Wuchereria bancrofti, Brugia malayi and Brugia timori. The aim of the Global Program to Eliminate LF (GPELF) is to interrupt LF transmission through mass drug administration (MDA) by 2020 and to alleviate the suffering of affected people. Mapping is the first programmatic step to determining areas of LF endemicity and establishing a national program. Ethiopia was believed to be endemic for LF, but until recently the distribution of LF in the country was unknown. From 2008–2013, mapping for LF was conducted using the current WHO protocol, and 112 woredas were identified as endemic or possibly endemic. In 45 of these 112 woredas, only a single CFA positive result was found (

Onchocerciasis is a severe parasitic infection which causes disabling skin and subcutaneous tissue changes. The disease is endemic in many African countries including Ethiopia. In 2013, Ethiopia launched Onchocerciasis elimination program with the goal of attaining interruption of onchocerciasis transmission nationwide by 2020. The country has successfully scaled up interventions and achieved 100% geographic coverage in all known endemic districts. The main strategy for interrupting the disease is mass drug administration (MDA) delivered two times per year. The treatment coverage for the last five years has been maintained at more than 80%. Despite many years of ivermectin MDA the transmission of onchocerciasis in many districts remained unabated. To achieve the 2020 goal, sustained high geographic and therapeutic coverage is required which is validated by coverage surveys. The programme should aim to improve the knowledge and attitude of the community towards the programme in order to improve drug compliance. The partnership between the relevant stakeholders should be strengthened to facilitate open discussions regarding the programme implementation and any challenges that may arise in the control and elimination of the disease. It is also important to consider intensified vector control.