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Background: Plasmodium vivax malaria is a leading cause of morbidity in Ethiopia. The first-line treatment for P. vivax is chloroquine (CQ) and primaquine (PQ), but there have been local reports of CQ resistance. A clinical study was conducted to determine the efficacy of CQ for the treatment of P. vivax malaria in southern Ethiopia., Methods: In 2021, patients with P. vivax mono-infection and uncomplicated malaria were enrolled and treated with 25 mg/kg CQ for 3 consecutive days. Patients were followed for 28 days according to WHO guidelines. The data were analysed using per-protocol (PP) and Kaplan‒Meier (K‒M) analyses to estimate the risk of recurrent P. vivax parasitaemia on day 28., Results: A total of 88 patients were enrolled, 78 (88.6%) of whom completed the 28 days of follow-up. Overall, 76 (97.4%) patients had adequate clinical and parasitological responses, and two patients had late parasitological failures. The initial therapeutic response was rapid, with 100% clearance of asexual parasitaemia within 48 h., Conclusion: Despite previous reports of declining chloroquine efficacy against P. vivax, CQ retains high therapeutic efficacy in southern Ethiopia, supporting the current national treatment guidelines. Ongoing clinical monitoring of CQ efficacy supported by advanced molecular methods is warranted to inform national surveillance and ensure optimal treatment guidelines., (© 2024. The Author(s).)

Background: Lymphatic filariasis (LF) is a debilitating, poverty-promoting, neglected tropical disease (NTD) targeted for worldwide elimination as a public health problem (EPHP) by 2030. Evaluating progress towards this target for national programmes is challenging, due to differences in disease transmission and interventions at the subnational level. Mathematical models can help address these challenges by capturing spatial heterogeneities and evaluating progress towards LF elimination and how different interventions could be leveraged to achieve elimination by 2030., Methods: Here we used a novel approach to combine historical geo-spatial disease prevalence maps of LF in Ethiopia with 3 contemporary disease transmission models to project trends in infection under different intervention scenarios at subnational level., Results: Our findings show that local context, particularly the coverage of interventions, is an important determinant for the success of control and elimination programmes. Furthermore, although current strategies seem sufficient to achieve LF elimination by 2030, some areas may benefit from the implementation of alternative strategies, such as using enhanced coverage or increased frequency, to accelerate progress towards the 2030 targets., Conclusions: The combination of geospatial disease prevalence maps of LF with transmission models and intervention histories enables the projection of trends in infection at the subnational level under different control scenarios in Ethiopia. This approach, which adapts transmission models to local settings, may be useful to inform the design of optimal interventions at the subnational level in other LF endemic regions., Competing Interests: Potential conflicts of interest. E. M. reports that they received grant funding from the National Institutes of Health, Microsoft Research, and Florida Blue Foundation. W. A. S. reports being a member of the Ethiopian Onchocercias Elimination Expert Advisory Committee (EOEEAC) and received funding to attend EOEEAC meetings. S. E. F. S. reports receiving research funding from EndFund. H. S. F. reports funding from the Department of International Development (UK), the Task Force for Global Health, RTI, and EndFund, honoraria paymenst from Task force for Global Health and RTI, and support for attending meetings from the Task Force for Global Health. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: The impact of access to improved water, sanitation and hygiene (WASH) and health education on large-scale deworming programs aimed at controlling soil-transmitted helminth (STH) and schistosome (SCH) infections has not been well studied. We assessed the additional impact of improved WASH infrastructure and health education at schools on STH and SCH infections in Ethiopia., Methods: The study used a quasi-experimental design under which 30 schools were assigned to either an intervention (15 schools) or control (15 schools) arm. Both arms received a standard deworming treatment and lunch. In the intervention arm, improved WASH and health education were provided. At three consecutive time points (baseline in 2013, 2014 and 2015), the prevalence and intensity of STH and SCH infections and the nutritional status [hemoglobin concentrations and physical growth (height and weight)] were determined. To verify whether interventions were successfully implemented, the WASH status at school and the student knowledge, attitudes and practices related to WASH (WASH-KAP) were recorded. Differences in metrics between arms at baseline (2013) and follow-up (2015) were assessed both within and between the arms., Results: A significant increase in scores for both the school WASH and student KAP was found in the intervention arm, indicating successful implementation of the intervention. The prevalence of any STH infection was significantly reduced in the intervention arm but not in the control arm (F = 4.486, p = 0.034). There was a significantly greater reduction in the intensity of infection of hookworm and Ascaris lumbricoides compared to baseline in both arms. The intervention did not affect school children's height-for-age z-score (intervention arm * time coef = 0.12, p = 0.400) and body mass index-for-age z-scores (intervention * time coef = - 0.06, p = 0.526). Hemoglobin concentrations increased significantly more in the control than the intervention arm (coef = - 0.16, p = 0.006)., Conclusions: Although the intervention did increase school WASH and student WASH-KAP, our study found poor evidence of the additional benefit of improved WASH and health education to deworming and school food programs on parasite re-infection and the health outcomes of children., (© 2024. The Author(s).)

Cryptosporidium, Shigella, toxin-producing Escherichia coli, and rotavirus were reported to be the most responsible for severe and fatal diarrhea among infants. This study aimed to investigate the presence of these pathogens in infants' drinking water samples and analyzing using water quality determinants in eastern Ethiopia. A molecular (LAMP)-based cross-sectional study design was employed. A total of 410 and 37 water samples were tested from infant point-of-use at household and corresponding water source, respectively, from June 2020 to May, 2021. Cryptosporidium, Shigella, toxin-producing E. coli, and rotavirus were detected in 28.5, 30.0, 26.3, and 32.2%, of water samples tested from infant point-of-use, respectively. About 13.2% of the water samples were positive for all (four) pathogens together. Cryptosporidium, Shigella, toxin-producing E. coli, and rotavirus were detected in 27.0, 32.4, 29.7, and 37.8%, of water samples tested from water sources, respectively. Positive significant correlation was observed between infant point-of-consumption and water sources from which it is drawn toward the presence of each targeted pathogen. Unimproved water source showed a strong significant association with the presence of Cryptosporidium, Shigella and toxin-producing E. coli. Therefore, efforts should be made in development of improved water sources, source protection safety and health education to caretakers of infants.

Background: Critically ill children have a lower nutritional reserve, compounding the restricted food intake during intensive care unit (ICU) and hospital stays, and scarce data are available to point out the problem. Therefore, this review aimed to assess the pooled prevalence of malnutrition among critically ill children., Methodology: This systematic review was conducted in accordance with the JBI methodology for systematic reviews of prevalence and incidence. Databases including, PubMed/MEDLINE, CINAHL/EBSCO, HINARI, Google Scholar, and gray literatures were used to find relevant articles. Eligible studies were critically appraised by two independent reviewers. Systematic review and meta-analysis was conducted using STATA 17 software. Funnel plot and at the 5% significance level, Egger's test were used to check for publication bias., Result: From a total of 15 studies with 4331 study participants, the pooled prevalence of malnutrition in critically ill children was 37.19% (95% CI; 35.89-38.49) with a significant statistical heterogeneity (I 2  = 98.6, P = < 0.0001). High income countries reported the lower pooled prevalence of malnutrition among critically ill children (30.14%, 95% CI; 28.41, 31.88). No publication bias was reported and sensitivity analysis suggested that no significance difference was shown in the prevalence of malnutrition among critically ill children with the pooled prevalence., Conclusion: The current systematic review and meta-analysis showed that more than one in three critically ill children was malnourished. Serious medical conditions in children that deserve admission to the intensive care unit could be a complication of malnutrition that may end up in deaths unless the undernutrition is addressed together with critical care intervention. Hence, specific strategies to prevent malnutrition among this neglected segment should be integrated with the existing healthcare systems and nutritional programs., (© 2023. The Author(s).)

Background: Non-communicable diseases (NCDs) pose a substantial global health challenge, resulting in an annual death toll of over 15 million individuals aged 30 to 69. Ethiopia, categorized as COVID-19 vulnerable, grapples with NCD treatment challenges. This study aims to assess disease service availability at primary health units in Ethiopia during the pandemic., Methods: A facility-based cross-sectional study was conducted from October to December 2021 across regions, encompassing 452 facilities: 92 health centers, 16 primary hospitals, 344 health posts, and 43 districts. Facility selection, based on consultation with regional health bureaus, included high, medium, and low performing establishments. The study employed the WHO tool for COVID-19 capacity assessment and evaluated services for various diseases using descriptive analysis., Results: Results reveal service disruptions in the past year: hospitals (55.6%), health centers (21.7%), districts (30.2%), and health posts (17.4%). Main reasons were equipment shortages (42%), lack of skilled personnel (24%), and insufficient infection prevention supplies (18.8%). While tuberculosis treatment was fully available in 23% of health posts and malaria services in 65.7%, some health centers lacked HIV/AIDS, cardiovascular, mental health, and cervical cancer services. Most communicable and non-communicable disease diagnoses and treatments were fully accessible at primary hospitals, except for cervical cancer (56.3%) and mental health (62.5%) services., Conclusion: Significant gaps exist in expected services at primary health units. Improving disease care accessibility necessitates strengthening the supply chain, resource management, capacity building, and monitoring systems., (© 2023 Tajebew ZG, et al.)

Background: The emergence of COVID-19 pandemic has disrupted the supply chain and stock of medicines and drugs across the globe. Tracer drugs are essential medicines that address the population's priority health problems. Thus, this study aimed to assess availability of tracer drugs and basic diagnostics at public primary health care facilities in Ethiopia., Methods: Facility based cross-sectional study was employed in four regions and one city administration. The primary health care units (PHCUs) were purposively selected in consultation with respective regional health bureaus. Finally, 16 hospitals, 92 health centers and 344 health posts were included. This study adopted WHO's tool that was being used to rapidly assess the capacity of health facilities to maintain the provision of essential health services during the COVID-19. Descriptive analysis was done using frequency and percentage, and results were presented., Results: The overall mean availability of tracer drugs in PHCUs was 77.6%. Only 2.8% of PHCUs have all tracer drugs. The mean availability of basic diagnostic at national level was 86.6% in PHUs except health posts where it was less. Health facilities with all basic diagnostic services was 53.7%. Of the total 344 health posts assessed, 71% were providing diagnostic testing for malaria using either laboratory equipment or rapid diagnostic test (RDT) while 43% provide urine test for the pregnancy., Conclusion: This study shows availability of all tracer drugs in PHCUs in Ethiopia was extremely low. There was regional variation in availability of tracer drugs and basic diagnostics. It is very crucial to increase availability of tracer drugs and diagnostics. Drugs and diagnostic materials should be supplied according to the capacity and location of health facilities., (© 2023 Abdurezak U., et al.)

Background: The COVID-19 pandemic is putting a pressure on global health systems. The disruption of essential health services (EHS) has an impact on the health of mothers, neonate and children in developing countries. Therefore, the main aim of this study was assessing the availability of Maternal, Newborn care and Child health (MNCHS) services at primary health care unit during COVID-19 outbreak., Methods: A cross-sectional survey was conducted in five regions of Ethiopia in 2021. Descriptive analyses were undertaken using STATA 16 software and the results presented using tables and different graphs. A continuity of EHS assessment tool adopted from WHO was used for data collection., Result: During COVID -19 pandemic, 30 (69.8%) of woreda health offices, 52 (56.5%) of health centers (HCs), 7 (44.4%) of hospitals, and 165 (48%) of health posts (HPs) had a defined list of EHS. In comparison with other EHS, family planning is the least available service in all regions. At HPs level care for sick children and antenatal care (ANC) were available at 59.1 and 58.82% respectively. Except immunization services at SNNP, all other maternal, newborn, and child health EHS were not available to all HPs at full scale., Conclusion: Immunization services were most available, while ANC and care for sick children were least available during COVID-19 at the HPs level. There was regional variation in MNCH EHS service availability at all levels., (© 2023 Berhanu F, et al.)

Background: Essential health services are a package of services critical to improve health outcomes. COVID-19 pandemic disrupts essential health services. However, the level of essential health service disruption due to COVID-19 in Ethiopia is not clear. This study aimed at measuring the status of delivery of essential health services in Ethiopia during COVID-19., Methods: A national mixed-methods cross-sectional survey was conducted. It was undertaken in Amhara (10 districts), Oromia (eight districts), Sidama (six districts), Southern Nations, Nationalities, and People's Region (16 districts), and Dire Dawa City Administration. A total of 452 health facilities were surveyed. Data were collected using face-to-face interview. Descriptive analysis was undertaken. Qualitative data was analyzed thematically., Results: The woredas (districts) and health facilities which adopted essential health services before the COVID-19 pandemic were 81.4% and 51.2%, respectively. Nearly all health centers provided antenatal care services. Blood pressure measuring apparatus and delivery set were available in all health centers. However, only 50% of health centers had radiant warmer. Malnutrition services were provided by 47% of rural health centers. Moreover, a functional incinerator was available in only 41% of health centers. The provision of cardiovascular disease management was at 27.2%. Furthermore, HIV/AIDS treatment was provided by 43.5% of health facilities., Conclusion: The adoption of lists of essential health services was optimal. The status of delivery of essential health services was high for maternal healthcare. Neonatal care at birth, malnutrition treatment, and cardiovascular disease management were low. The district health system should strive more to maintain essential health services., (© 2023 Elias AY, et al.)

Background: Early case detection and prompt treatment are important malaria control and elimination strategies. However, the emergence and rapid spread of drug-resistant strains present a major challenge. This study reports the first therapeutic efficacy profile of pyronaridine-artesunate against uncomplicated Plasmodium falciparum in Northwest Ethiopia., Methods: This single-arm prospective study with 42-day follow-up period was conducted from March to May 2021 at Hamusit Health Centre using the World Health Organization (WHO) therapeutic efficacy study protocol. A total of 90 adults ages 18 and older with uncomplicated falciparum malaria consented and were enrolled in the study. A standard single-dose regimen of pyronaridine-artesunate was administered daily for 3 days, and clinical and parasitological outcomes were assessed over 42 days of follow-up. Thick and thin blood films were prepared from capillary blood and examined using light microscopy. Haemoglobin was measured and dried blood spots were collected on day 0 and on the day of failure., Results: Out of 90 patients, 86/90 (95.6%) completed the 42-day follow-up study period. The overall PCR-corrected cure rate (adequate clinical and parasitological response) was very high at 86/87 (98.9%) (95% CI: 92.2-99.8%) with no serious adverse events. The parasite clearance rate was high with fast resolution of clinical symptoms; 86/90 (95.6%) and 100% of the study participants cleared parasitaemia and fever on day 3, respectively., Conclusion: Pyronaridine-artesunate was highly efficacious and safe against uncomplicated P. falciparum in this study population., (© 2023. The Author(s).)

Background: The development of drug resistance to chloroquine is posing a challenge in the prevention and control efforts of malaria globally. Chloroquine is the first-line treatment for uncomplicated P.vivax in Ethiopia. Regular monitoring of anti-malarial drugs is recommended to help early detection of drug-resistant strains of malaria parasites before widely distributed. The emergence of P.vivax resistance to chloroquine in the country endangers the efficacy of P.vivax treatment. This study aimed to assess the therapeutic efficacy of chloroquine among uncomplicated P.vivax infections at Shewa Robit Health Center, northeast Ethiopia., Methods: One-arm in vivo prospective chloroquine efficacy study was conducted from November 2020 to March 2021. Ninety participants aged between 16 months to 60 years confirmed with P.vivax mono-infection microscopically were selected and treated with a 25 mg/kg standard dose of chloroquine over three days. Thick and thin blood smears were prepared and examined. Clinical examination was performed over 28 follow-up days. Hemoglobin concentration level was measured on days 0, 14, and 28., Result: Of the 90 enrolled participants, 86 (96%) completed their 28 days follow-up period. The overall cure rate of the drug was 98.8% (95% CI: 95.3-100%). All asexual stages and gametocytes were cleared within 48 hours with rapid clearance of fever. Hemoglobin concentration had significantly recovered between days 0 and 14, 0 and 28, and 14 and 28 days (P = 0.032, P<0.001, and P = 0.005), respectively. Fast resolution of clinical signs and symptoms was also observed. Severe adverse events were not recorded., Conclusion: The present study revealed that chloroquine remains an efficacious and safe drug in the study setting for treating uncomplicated P.vivax in the study area. Large-scale continuous surveillance is needed to monitor the development of resistance in due time., Competing Interests: The authors have declared that no competing interest exists., (Copyright: © 2023 Belay et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In 2004, Ethiopia adopted artemether-lumefantrine (AL, Coartem ® ) as first-line treatment for the management of uncomplicated Plasmodium falciparum malaria. Continuous monitoring of AL therapeutic efficacy is crucial in Ethiopia, as per the World Health Organization (WHO) recommendation. This study aimed to assess the therapeutic efficacy of AL in the treatment of uncomplicated P. falciparum infection., Methods: A 28 day onearm, prospective evaluation of the clinical and parasitological response to AL was conducted at Shecha Health Centre, Arba Minch town, Southern Ethiopia. Patients were treated with six-dose regimen of AL over three days and monitored for 28 days with clinical and laboratory assessments. Participant recruitment and outcome classification was done in accordance with the 2009 WHO methods for surveillance of anti-malarial drug efficacy guidelines., Results: A total of 88 study participants were enrolled and 69 of them completed the study with adequate clinical and parasitological response. Two late parasitological failures were observed, of which one was classified as a recrudescence by polymerase chain reaction (PCR). The PCRcorrected cure rate was 98.6% (95% CI 92.3-100). AL demonstrated a rapid parasite and fever clearance with no parasitaemia on day 2 and febrile cases on day 3. Gametocyte clearance was complete by day three. No serious adverse events were reported during the 28 days follow-up., Conclusion: The study demonstrated high therapeutic efficacy and good safety profile of AL. This suggests the continuation of AL as the first-line drug for the treatment of uncomplicated P. falciparum malaria in Ethiopia. Periodic therapeutic efficacy studies and monitoring of markers of resistance are recommended for early detection of resistant parasites., (© 2023. The Author(s).)

Background: Declining efficacy of chloroquine for the treatment Plasmodium vivax malaria has been reported in different endemic settings in Ethiopia. This highlights the need to assess alternative options for P. vivax treatment with artemisinin-based combination therapy, such as pyronaridine-artesunate. This treatment regimen has shown high efficacy for uncomplicated malaria in both Africa and Asia. However, limited data are available from Ethiopia. This study was conducted to assess the efficacy and safety of pyronaridine-artesunate for the treatment of uncomplicated P. vivax malaria in Northwest Ethiopia., Methods: A single arm prospective efficacy study was conducted in the Hamusite area, Northwest Ethiopia. Fifty-one febrile adult patients with uncomplicated P. vivax malaria were enrolled between March and July 2021. Patients were treated with pyronaridine-artesunate once daily for three days. Clinical and parasitological parameters were monitored over a 42-day follow-up period using the standard World Health Organization protocol for therapeutic efficacy studies., Results: A total of 4372 febrile patients were screened with 51 patients enrolled and 49 completing the 42-day follow-up period. The PCR-uncorrected adequate clinical and parasitological response (ACPR) was 95.9% (47/49; 95% CI 84.9-99.0) on day 42. Two patients had recurrences [4.0% (2/49); 95% CI 0.7-12.1] on days 35 and 42. The parasite clearance rate was rapid with fast resolution of clinical symptoms; 100% of participants had cleared parasitaemia on day 1 and fever on day 2. All 16 (31.4%) patients with gametocyte carriage on day 0 had cleared by day 1. There were no serious adverse events., Conclusion: In this small study, pyronaridine-artesunate was efficacious and well-tolerated for the treatment of uncomplicated P. vivax malaria. In adults in the study setting, it would be a suitable alternative option for case management., (© 2022. The Author(s).)

Background: Routine monitoring of anti-malarial drugs is recommended for early detection of drug resistance and to inform national malaria treatment guidelines. In Ethiopia, the national treatment guidelines employ a species-specific approach. Artemether-lumefantrine (AL) and chloroquine (CQ) are the first-line schizonticidal treatments for Plasmodium falciparum and Plasmodium vivax, respectively. The National Malaria Control and Elimination Programme in Ethiopia is considering dihydroartemisinin-piperaquine (DHA/PPQ) as an alternative regimen for P. falciparum and P. vivax., Methods: The study assessed the clinical and parasitological efficacy of AL, CQ, and DHA/PPQ in four arms. Patients over 6 months and less than 18 years of age with uncomplicated malaria mono-infection were recruited and allocated to AL against P. falciparum and CQ against P. vivax. Patients 18 years or older with uncomplicated malaria mono-infection were recruited and randomized to AL or dihydroartemisinin-piperaquine (DHA/PPQ) against P. falciparum and CQ or DHA/PPQ for P. vivax. Patients were followed up for 28 (for CQ and AL) or 42 days (for DHA/PPQ) according to the WHO recommendations. Polymerase chain reaction (PCR)-corrected and uncorrected estimates were analysed by Kaplan Meier survival analysis and per protocol methods., Results: A total of 379 patients were enroled in four arms (n = 106, AL-P. falciparum; n = 75, DHA/PPQ- P. falciparum; n = 142, CQ-P. vivax; n = 56, DHA/PPQ-P. vivax). High PCR-corrected adequate clinical and parasitological response (ACPR) rates were observed at the primary end points of 28 days for AL and CQ and 42 days for DHA/PPQ. ACPR rates were 100% in AL-Pf (95% CI: 96-100), 98% in CQ-P. vivax (95% CI: 95-100) at 28 days, and 100% in the DHA/PPQ arms for both P. falciparum and P. vivax at 42 days. For secondary endpoints, by day three 99% of AL-P. falciparum patients (n = 101) cleared parasites and 100% were afebrile. For all other arms, 100% of patients cleared parasites and were afebrile by day three. No serious adverse events were reported., Conclusion: This study demonstrated high therapeutic efficacy for the anti-malarial drugs currently used by the malaria control programme in Ethiopia and provides information on the efficacy of DHA/PPQ for the treatment of P. falciparum and P. vivax as an alternative option., (© 2022. The Author(s).)

Background: Declining efficacy of chloroquine against Plasmodium vivax malaria has been documented in Ethiopia. Thus, there is a need to assess the efficacy of alternative schizontocidal anti-malarials such as dihydroartemisinin-piperaquine (DHA-PPQ) in P. vivax malaria-infected patients. This study was conducted to evaluate the therapeutic efficacy of DHA-PPQ drug in South West Ethiopia., Methods: This is a single-arm, prospective therapeutic efficacy study in patients with uncomplicated P. vivax malaria. The study was conducted from May 2021 to August 2021, based on the standard World Health Organization study protocol for surveillance of anti-malarial therapeutic efficacy. The study endpoint was adequate clinical and parasitological response on day 42., Results: A total of 86 patients with uncomplicated vivax malaria were enrolled. Of these, 79 patients completed the scheduled follow up; all showing adequate clinical and parasitological responses to day 42, with a successful cure rate of 100% (95% CI 96-100). Parasitaemias were cleared rapidly (86% by day 1 and 100% by day 3), as were clinical symptoms (100% by day 1). Gametocyte carriage decreased from 44% on Day 0 to 1% on day 1 and 0% on Day 2. Mean haemoglobin concentrations increased between day 0 (mean 12.2 g/dL) and day 42 (mean 13.3 g/dL). Treatment was well tolerated and no severe adverse events were observed., Conclusion: In summary, treatment with DHA-PPQ demonstrated excellent efficacy for uncomplicated P. vivax, with no recurrences to day 42, and no safety concerns. This treatment, which is also effective against P. falciparum, appears to be an ideal alternative for P. vivax as part of the malaria elimination programme., (© 2022. The Author(s).)

Objective: To assess the preference of birth attendant gender and associated factors among antenatal care attendants in Debre Markos town public health facilities, northwest Ethiopia, 2021., Method: A facility-based cross-sectional study was conducted from 8 January 2021 to 28 February 2021 at Debre Markos town public health facilities. A total of 662 study participants were selected by systematic random sampling technique. Pretested interviewer-administered structured questionnaires were used for data collection. Data were entered using Epi Data version 3.1 and analyzed using SPSS version 25. Bivariable and multivariable logistic regression were applied to identify factors associated with birth attendant gender preference. Association was described by the "odd ratio" along with a 95% confidence interval. Finally, a P value < 0.05 in the adjusted analysis was used to declare a significant association., Result: In this study, 644 women participated making a response rate of 97.3%. Of the total study participants, 108 (16.8%; 95% confidence interval: 13.8-19.4) preferred male birth attendants, while 232 (36%; 95% confidence interval: 32.5-39.8) preferred female birth attendants. Age (15-24) (adjusted odds ratio = 4.81, 95% confidence interval: 1.79, 12.94), no formal education (adjusted odds ratio = 2.94, 95% confidence interval: 1.32, 6.52), and primary education (adjusted odds ratio = 2.42, 95% confidence interval: 1.07, 5.47) were significantly associated with female birth attendant preference. A lack of formal education (adjusted odds ratio = 0.08; 95% confidence interval: 0.01, 0.68), secondary education (adjusted odds ratio = 0.34; 95% confidence interval: 0.16, 0.71), and history of assisted vaginal delivery (adjusted odds ratio = 3.72; 95% confidence interval: 1.40, 9.87) were significantly associated with a male birth attendant preference., Conclusion: A female birth attendant is preferred by almost one-third of pregnant mothers, while one-sixth preferred a male. The clients who were younger in age and lower in educational status were more likely to prefer female birth attendants, whereas those who had a history of assisted vaginal delivery were more likely to prefer male birth attendants. To have a mother in the continuum of care, it is crucial to take her preferences into account when providing services., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Background: The continued provision of safe food, free of aflatoxin remains a huge challenge in developing countries. Despite several favourable climatic conditions that facilitate aflatoxin contamination in Ethiopia, there is little information showing aflatoxin exposure in children. Therefore, this study assessed aflatoxin exposure among young children in Butajira district, South-Central Ethiopia., Methods: Community based cross-sectional study stratified by agro-ecology was employed in Health and Demographic Surveillance Site (HDSS) of Butajira. The study included 332 children aged 12-59 months and were selected by simple random sampling technique using the HDSS registration number as a sampling frame. We collected data on dietary practice and aflatoxin exposure. Aflatoxin M1 concentration in urine was measured by Enzyme-Linked Immunosorbent assay (ELISA). The data analysis was carried out using STATA., Results: Detectable urinary Aflatoxin M1 was found in 62.4% (95% CI: 56.9 - 67.5%) of the children at a level ranging from 0.15 to 0.4 ng/ml. Children living in lowland agro-ecological zone had [AOR = 2.11 (95% CI; 1.15, 3.88] odds of being exposed to aflatoxin as compared to children living in highland agro-ecological zone. Children at lower socio-economic status [AOR = 0.27 (95% CI; 0.14, 0.50] and medium socio-economic status [AOR = 0.47 (95% CI; 0.25, 0.87] had 73% and 53% lower odds of being exposed to aflatoxin as compared to children in the higher socio-economic status, respectively., Conclusions: Aflatoxin exposure among young children was very high in South-Central Ethiopia. This high aflatoxin exposure might emphasize the need for aflatoxin exposure mitigation strategies in Ethiopia. Especially, raising awareness of the community towards aflatoxin exposure is very crucial. In addition, further research is required to assess long-term aflatoxin exposure and its association with child growth and development., (© 2022. The Author(s).)

Background: Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis of both symptomatic and asymptomatic infections. Although RDTs are a reliable and practical diagnostic tool, the sensitivity of histidine-rich protein 2 (HRP2)-based RDTs can be reduced if pfhrp2 or pfhrp3 (pfhrp2/3) gene deletions exist in the Plasmodium falciparum parasite population. This study evaluated dried blood spot (DBS) samples collected from a national household survey to investigate the presence of pfhrp2/3 deletions and the performance of the RDT used in the cross-sectional survey in a low transmission setting., Methods: The 2015 Ethiopia Malaria Indicator Survey tested household members by RDT and collected DBS samples. DBS (n = 2648) from three regions in northern Ethiopia were tested by multiplex bead-based antigen detection assay after completion of the survey. The multiplex assay detected pan-Plasmodium lactate dehydrogenase (LDH), pAldolase, and HRP2 antigens in samples. Samples suspected for pfhrp2/3 gene deletions (pLDH and/or pAldolase positive but low or absent HRP2) were further investigated by molecular assays for gene deletions. Antigen results were also compared to each individual's RDT results. Dose-response logistic regression models were fit to estimate RDT level of detection (LOD) antigen concentrations at which 50, 75, 90, and 95% of the RDTs returned a positive result during this survey., Results: Out of 2,648 samples assayed, 29 were positive for pLDH or pAldolase antigens but low or absent for HRP2 signal, and 15 of these samples (51.7%) were successfully genotyped for pfhrp2/3. Of these 15 P. falciparum infections, eight showed single deletions in pfhrp3, one showed a single pfhrp2 deletion, and six were pfhrp2/3 double-deletions. Six pfhrp2 deletions were observed in Tigray and one in Amhara. Twenty-five were positive for HRP2 by the survey RDT while the more sensitive bead assay detected 30 HRP2-positive samples. A lower concentration of HRP2 antigen generated a positive test result by RDT compared to pLDH (95% LOD: 16.9 ng/mL vs. 319.2 ng/mL, respectively)., Conclusions: There is evidence of dual pfhrp2/3 gene deletions in the Tigray and Amhara regions of Ethiopia in 2015. As the prevalence of malaria was very low (< 2%), it is difficult to make strong conclusions on RDT performance, but these results challenge the utility of biomarkers in household surveys in very low transmission settings., (© 2022. The Author(s).)

Background: Determining malaria transmission within regions of low, heterogenous prevalence is difficult. A variety of malaria tests exist and range from identification of diagnostic infection to testing for prior exposure. This study describes the concordance of multiple malaria tests using data from a 2015 household survey conducted in Ethiopia., Methods: Blood samples (n=2279) from 3 regions in northern Ethiopia were assessed for Plasmodium falciparum and Plasmodium vivax by means of microscopy, rapid diagnostic test, multiplex antigen assay, and multiplex assay for immunoglobulin G (IgG) antibodies. Geospatial analysis was conducted with spatial scan statistics and kernel density estimation to identify malaria hot spots by different test results., Results: The prevalence of malaria infection was low (1.4% by rapid diagnostic test, 1.0% by microscopy, and 1.8% by laboratory antigen assay). For P. falciparum, overlapping spatial clusters for all tests and an additional 5 unique IgG clusters were identified. For P. vivax, clusters identified with bead antigen assay, microscopy, and IgG partially overlapped., Conclusions: Assessing the spatial distribution of malaria exposure using multiple metrics can improve the understanding of malaria transmission dynamics in a region. The relative abundance of antibody clusters indicates that in areas of low transmission, IgG antibodies are a more useful marker to assess malaria exposure., (Published by Oxford University Press for the Infectious Diseases Society of America 2021.)

Background: Abnormal blood glucose level is one of the most frequently encountered problems in children with severe illnesses. However, its magnitude and outcome have rarely been determined in Ethiopia. We aimed to determine the magnitude, associated factors and outcome of dysglycemia in critically ill children admitted to Jimma Medical Center., Methods: Prospective longitudinal study was conducted on children aged 28 days to 14 years admitted with critical illnesses at the different units of the Department of Pediatrics and Child Health of Jimma Medical Center, Southwest Ethiopia, from June to August 2019. Data were collected by trained medical personnel using structured questionnaire and analyzed using Statistical Package for Social Sciences (SPSS) windows version 20.0. Dysglycemia was considered whenever the child had a random blood sugar >150mg/dl or <45mg/dl., Result: Dysglycemia was seen at admission in 139/481, 28.9% children; 24 (5.0%) had hypoglycemia whereas 115 (23.9%) had hyperglycemia. The factors associated with dysglycemia at admission were severe acute malnutrition (p=002, AOR=3.09, CI=1.18,7.77), impaired mental status (p=0.003, AOR=4.63, CI=1.68, 12.71), place of residence (p=0.01, AOR=1.85, CI=1.15-2.96) and presence of diarrhea on date of admission. Among the children who had dysglycemia at admission, 16/139, 11.5% died., Conclusion: Dysglycemia is a common problem in critically ill children in the setting. Blood glucose level should be determined for all critically ill children, and routine empirical administration of dextrose should be minimized since most of the children with dysglycemia had hyperglycemia than hypoglycemia., (© 2021 Habtamu Sime, et al.)

The Coronavirus pandemic is recording unprecedented deaths worldwide. The temporal distribution and burden of the disease varies from setting to setting based on economic status, demography and geographic location. A rapid increase in the number of COVID-19 cases is being reported in Africa as of June 2020. Ethiopia reported the first COVID-19 case on 13 March 2020. Limited molecular laboratory capacity in resource constrained settings is a challenge in the diagnosis of the ever-increasing cases and the overall management of the disease. In this article, the Ethiopian Public Health Institute (EPHI) shares the experience, challenges and prospects in the rapid establishment of one of its COVID-19 testing laboratories from available resources. The first steps in establishing the COVID-19 molecular testing laboratory were i) identifying a suitable space ii) renovating it and iii) mobilizing materials including consumables, mainly from the Malaria and Neglected Tropical Diseases (NTDs) research team at the EPHI. A chain of experimental design was set up with distinct laboratories to standardize the extraction of samples, preparation of the master mix and detection. At the commencement of sample reception and testing, laboratory contamination was among the primary challenges faced. The source of the contamination was identified in the master mix room and resolved. In summary, the established COVID-19 testing lab has tested more than 40,000 samples (August 2020) and is the preferred setting for research and training. The lessons learned may benefit the further establishment of emergency testing laboratories for COVID-19 and/or other epidemic/pandemic diseases in resource-limited settings.

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: National deworming programmes rely almost exclusively on mass drug administration (MDA) to children to control morbidity caused by these parasitic infections. The provision of other interventions, consisting of preventive chemotherapy at high population level coverage together with water, sanitation and hygiene (WaSH) and changes in risk behaviour, should enable sustainable control of soil-transmitted helminths (STH) and schistosomiasis and ultimately interrupt transmission., Methods/design: Two interventions will be implemented by the project: (i) community-wide biannual albendazole and annual praziquantel treatment with a target of 80-90% treatment coverage ("expanded MDA"); and (ii) provision of WaSH with behaviour change communication (BCC), within the Wolaita zone, Ethiopia. The project has three study arms: (i) expanded community-wide MDA, WaSH and BCC; (ii) expanded community-wide MDA only; and (iii) annual school-based MDA (the current National STH/schistosomiasis Control Programme). The impact of these interventions will be evaluated through prevalence mapping at baseline and endline (after four rounds of MDA), combined with annual longitudinal parasitological surveillance in defined cohorts of people to monitor trends in prevalence and reinfection throughout the project. Treatment coverage and individual compliance to treatment will be monitored by employing fingerprint biometric technology and barcoded identification cards at treatment. WaSH utilisation will be evaluated through school and household level observations and annual WaSH assessment survey. Complementary qualitative surveys will explore practices, cultural and social drivers of risk behaviours, uptake of WaSH and treatment, and assessing the impact of the BCC., Discussion: The study has the potential to define an 'End Game' for STH and schistosomiasis programmes through provision of multiple interventions. Interrupting transmission of these infections would eliminate the need for long-term repeated MDA, lead to sustained health improvements in children and adults, thereby allowing health systems to focus on other disease control priorities.

Background: Measures of malaria burden using microscopy and rapid diagnostic tests (RDTs) in cross-sectional household surveys may incompletely describe the burden of malaria in low-transmission settings. This study describes the pattern of malaria transmission in Ethiopia using serological antibody estimates derived from a nationwide household survey completed in 2015., Methods: Dried blood spot (DBS) samples were collected during the Ethiopian Malaria Indicator Survey in 2015 from malarious areas across Ethiopia. Samples were analysed using bead-based multiplex assays for IgG antibodies for six Plasmodium antigens: four human malaria species-specific merozoite surface protein-1 19kD antigens (MSP-1) and Apical Membrane Antigen-1 (AMA-1) for Plasmodium falciparum and Plasmodium vivax. Seroprevalence was estimated by age, elevation and region. The seroconversion rate was estimated using a reversible catalytic model fitted with maximum likelihood methods., Results: Of the 10,278 DBS samples available, 93.6% (9622/10,278) had valid serological results. The mean age of participants was 15.8 years and 53.3% were female. National seroprevalence for antibodies to P. falciparum was 32.1% (95% confidence interval (CI) 29.8-34.4) and 25.0% (95% CI 22.7-27.3) to P. vivax. Estimated seroprevalences for Plasmodium malariae and Plasmodium ovale were 8.6% (95% CI 7.6-9.7) and 3.1% (95% CI 2.5-3.8), respectively. For P. falciparum seroprevalence estimates were significantly higher at lower elevations (< 2000 m) compared to higher (2000-2500 m) (aOR 4.4; p < 0.01). Among regions, P. falciparum seroprevalence ranged from 11.0% (95% CI 8.8-13.7) in Somali to 65.0% (95% CI 58.0-71.4) in Gambela Region and for P. vivax from 4.0% (95% CI 2.6-6.2) in Somali to 36.7% (95% CI 30.0-44.1) in Amhara Region. Models fitted to measure seroconversion rates showed variation nationally and by elevation, region, antigen type, and within species., Conclusion: Using multiplex serology assays, this study explored the cumulative malaria burden and regional dynamics of the four human malarias in Ethiopia. High malaria burden was observed in the northwest compared to the east. High transmission in the Gambela and Benishangul-Gumuz Regions and the neglected presence of P. malariae and P. ovale may require programmatic attention. The use of a multiplex assay for antibody detection in low transmission settings has the potential to act as a more sensitive biomarker.

Background: Building on the declining trend of malaria in Ethiopia, the Federal Ministry of Health aims to eliminate malaria by 2030. As Plasmodium falciparum and Plasmodium vivax are co-endemic in Ethiopia, the use of primaquine is indicated for both transmission interruption and radical cure, respectively. However, the limited knowledge of the local prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency and its associated variants has hindered the use of primaquine., Methods: Some 11,138 dried blood spot (DBS) samples were collected in 2011 as part of a national, household Malaria Indicator Survey, a multi-stage nationally representative survey of all malaria-endemic areas of Ethiopia. A randomly selected sub-set of 1414 DBS samples was successfully genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. Considering the geographical position and ethnic mix of the country, three common variants: G6PD*A (A376G), G6PD*A- (G202A) and Mediterranean (C563T) were investigated., Results: Of the 1998 randomly selected individuals, 1429 (71.5%) DBS samples were genotyped and merged to the database, of which 53.5% were from females. G6PD*A (A376G) was the only genotype detected. No sample was positive for either G6PD*A- (G202A) or Mediterranean (C563T) variants. The prevalence of G6PD*A (A376G) was 8.9% [95% confidence interval (CI) 6.7-11.2] ranging from 12.2% in the Southern Nations, Nationalities and Peoples' (95% CI 5.7-18.7) to none in Dire Dawa/Harari Region., Conclusion: The common G6PD*A- (G202A) or Mediterranean (C563T) variants were not observed in this nationwide study. The observed G6PD*A (A376G) mutation has little or no clinical significance. These findings supported the adoption of primaquine for P. falciparum transmission interruption and radical cure of P. vivax in Ethiopia. As the presence of other clinically important, less common variants cannot be ruled out, the implementation of radical cure will be accompanied by active haematological and adverse events monitoring in Ethiopia.

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.

Endemicity mapping is required to determining whether a district requires mass drug administration (MDA). Current guidelines for mapping LF require that two sites be selected per district and within each site a convenience sample of 100 adults be tested for antigenemia or microfilaremia. One or more confirmed positive tests in either site is interpreted as an indicator of potential transmission, prompting MDA at the district-level. While this mapping strategy has worked well in high-prevalence settings, imperfect diagnostics and the transmission potential of a single positive adult have raised concerns about the strategy's use in low-prevalence settings. In response to these limitations, a statistically rigorous confirmatory mapping strategy was designed as a complement to the current strategy when LF endemicity is uncertain. Under the new strategy, schools are selected by either systematic or cluster sampling, depending on population size, and within each selected school, children 9-14 years are sampled systematically. All selected children are tested and the number of positive results is compared against a critical value to determine, with known probabilities of error, whether the average prevalence of LF infection is likely below a threshold of 2%. This confirmatory mapping strategy was applied to 45 districts in Ethiopia and 10 in Tanzania, where initial mapping results were considered uncertain. In 42 Ethiopian districts, and all 10 of the Tanzanian districts, the number of antigenemic children was below the critical cutoff, suggesting that these districts do not require MDA. Only three Ethiopian districts exceeded the critical cutoff of positive results. Whereas the current World Health Organization guidelines would have recommended MDA in all 55 districts, the present results suggest that only three of these districts requires MDA. By avoiding unnecessary MDA in 52 districts, the confirmatory mapping strategy is estimated to have saved a total of $9,293,219.

Problem: Lymphatic filariasis and podoconiosis are the major causes of tropical lymphoedema in Ethiopia. The diseases require a similar provision of care, but until recently the Ethiopian health system did not integrate the morbidity management., Approach: To establish health-care services for integrated lymphoedema morbidity management, the health ministry and partners used existing governmental structures. Integrated disease mapping was done in 659 out of the 817 districts, to identify endemic districts. To inform resource allocation, trained health extension workers carried out integrated disease burden assessments in 56 districts with a high clinical burden. To ensure standard provision of care, the health ministry developed an integrated lymphatic filariasis and podoconiosis morbidity management guideline, containing a treatment algorithm and a defined package of care. Experienced professionals on lymphoedema management trained government-employed health workers on integrated morbidity management. To monitor the integration, an indicator on the number of lymphoedema-treated patients was included in the national health management information system., Local Setting: In 2014, only 24% (87) of the 363 health facilities surveyed provided lymphatic filariasis services, while 12% (44) provided podoconiosis services., Relevant Changes: To date, 542 health workers from 53 health centres in 24 districts have been trained on integrated morbidity management. Between July 2013 and June 2016, the national health management information system has recorded 46 487 treated patients from 189 districts., Lessons Learnt: In Ethiopia, an integrated approach for lymphatic filariasis and podoconiosis morbidity management was feasible. The processes used could be applicable in other settings where these diseases are co-endemic.

Lymphatic filariasis (LF) is one of the most debilitating and disfiguring diseases common in Ethiopia and is caused by Wuchereria bancrofti. Mapping for LF has shown that 70 woredas (districts) are endemic and 5.9 million people are estimated to be at risk. The national government's LF elimination programme commenced in 2009 in 5 districts integrated with the onchocerciasis programme. The programme developed gradually and has shown significant progress over the past 6 years, reaching 100% geographical coverage for mass drug administration (MDA) by 2016. To comply with the global LF elimination goals an integrated morbidity management and disability prevention (MMDP) guideline and a burden assessment programme has also been developed; MMDP protocols and a hydrocoele surgical handbook produced for country-wide use. In Ethiopia, almost all LF endemic districts are co-endemic with malaria and vector control aspects of the activities are conducted in the context of malaria programme as the vectors for both diseases are mosquitoes. In order to monitor the elimination, 11 sentinel and spot-check sites have been established and baseline information has been collected. Although significant achievements have been achieved in the scale up of the LF elimination programme, there is still a need to strengthen operational research to generate programme-relevant evidence, to increase access to morbidity management services, and to improve monitoring and evaluation of the LF programme. However, the current status of implementation of the LF national programme indicates that Ethiopia is poised to achieve the 2020 goal of elimination of LF. Nevertheless, to achieve this goal, high and sustained treatment coverage and strong monitoring and evaluation of the programme are essential.

Background: Mapping of lymphatic filariasis (LF) is essential for the delineation of endemic implementation units and determining the population at risk that will be targeted for mass drug administration (MDA). Prior to the current study, only 116 of the 832 woredas (districts) in Ethiopia had been mapped for LF. The aim of this study was to perform a nationwide mapping exercise to determine the number of people that should be targeted for MDA in 2016 when national coverage was anticipated., Methodology/principal Finding: A two-stage cluster purposive sampling was used to conduct a community-based cross-sectional survey for an integrated mapping of LF and podoconiosis, in seven regional states and two city administrations. Two communities in each woreda were purposely selected using the World Health Organization (WHO) mapping strategy for LF based on sampling 100 individuals per community and two purposely selected communities per woreda. Overall, 130 166 people were examined in 1315 communities in 658 woredas. In total, 140 people were found to be positive for circulating LF antigen by immunochromatographic card test (ICT) in 89 communities. Based on WHO guidelines, 75 of the 658 woredas surveyed in the nine regions were found to be endemic for LF with a 2016 projected population of 9 267 410 residing in areas of active disease transmission. Combining these results with other data it is estimated that 11 580 010 people in 112 woredas will be exposed to infection in 2016., Conclusions: We have conducted nationwide mapping of LF in Ethiopia and demonstrated that the number of people living in LF endemic areas is 60% lower than current estimates. We also showed that integrated mapping of multiple NTDs is feasible and cost effective and if properly planned, can be quickly achieved at national scale.

Background: Ethiopia is assumed to have the highest burden of podoconiosis globally, but the geographical distribution and environmental limits and correlates are yet to be fully investigated. In this paper we use data from a nationwide survey to address these issues., Methodology: Our analyses are based on data arising from the integrated mapping of podoconiosis and lymphatic filariasis (LF) conducted in 2013, supplemented by data from an earlier mapping of LF in western Ethiopia in 2008-2010. The integrated mapping used woreda (district) health offices' reports of podoconiosis and LF to guide selection of survey sites. A suite of environmental and climatic data and boosted regression tree (BRT) modelling was used to investigate environmental limits and predict the probability of podoconiosis occurrence., Principal Findings: Data were available for 141,238 individuals from 1,442 communities in 775 districts from all nine regional states and two city administrations of Ethiopia. In 41.9% of surveyed districts no cases of podoconiosis were identified, with all districts in Affar, Dire Dawa, Somali and Gambella regional states lacking the disease. The disease was most common, with lymphoedema positivity rate exceeding 5%, in the central highlands of Ethiopia, in Amhara, Oromia and Southern Nations, Nationalities and Peoples regional states. BRT modelling indicated that the probability of podoconiosis occurrence increased with increasing altitude, precipitation and silt fraction of soil and decreased with population density and clay content. Based on the BRT model, we estimate that in 2010, 34.9 (95% confidence interval [CI]: 20.2-51.7) million people (i.e. 43.8%; 95% CI: 25.3-64.8% of Ethiopia's national population) lived in areas environmentally suitable for the occurrence of podoconiosis., Conclusions: Podoconiosis is more widespread in Ethiopia than previously estimated, but occurs in distinct geographical regions that are tied to identifiable environmental factors. The resultant maps can be used to guide programme planning and implementation and estimate disease burden in Ethiopia. This work provides a framework with which the geographical limits of podoconiosis could be delineated at a continental scale.

Ethiopia has a diverse ecology and geography resulting in spatial and temporal variation in malaria transmission. Evidence-based strategies are thus needed to monitor transmission intensity and target interventions. A purposive selection of dried blood spots collected during cross-sectional school-based surveys in Oromia Regional State, Ethiopia, were tested for presence of antibodies against Plasmodium falciparum and P. vivax antigens. Spatially explicit binomial models of seroprevalence were created for each species using a Bayesian framework, and used to predict seroprevalence at 5 km resolution across Oromia. School seroprevalence showed a wider prevalence range than microscopy for both P. falciparum (0-50% versus 0-12.7%) and P. vivax (0-53.7% versus 0-4.5%), respectively. The P. falciparum model incorporated environmental predictors and spatial random effects, while P. vivax seroprevalence first-order trends were not adequately explained by environmental variables, and a spatial smoothing model was developed. This is the first demonstration of serological indicators being used to detect large-scale heterogeneity in malaria transmission using samples from cross-sectional school-based surveys. The findings support the incorporation of serological indicators into periodic large-scale surveillance such as Malaria Indicator Surveys, and with particular utility for low transmission and elimination settings., (© The American Society of Tropical Medicine and Hygiene.)

Although podoconiosis is one of the major causes of tropical lymphoedema and is endemic in Ethiopia its epidemiology and risk factors are poorly understood. Individual-level data for 129,959 individuals from 1,315 communities in 659 woreda (districts) were collected for a nationwide integrated survey of lymphatic filariasis and podoconiosis. Blood samples were tested for circulating Wuchereria bancrofti antigen using immunochromatographic card tests. A clinical algorithm was used to reach a diagnosis of podoconiosis by excluding other potential causes of lymphoedema of the lower limb. Bayesian multilevel models were used to identify individual and environmental risk factors. Overall, 8,110 of 129,959 (6.2%, 95% confidence interval [CI] 6.1-6.4%) surveyed individuals were identified with lymphoedema of the lower limb, of whom 5,253 (4.0%, 95% CI 3.9-4.1%) were confirmed to be podoconiosis cases. In multivariable analysis, being female, older, unmarried, washing the feet less frequently than daily, and being semiskilled or unemployed were significantly associated with increased risk of podoconiosis. Attending formal education and living in a house with a covered floor were associated with decreased risk of podoconiosis. Podoconiosis exhibits marked geographical variation across Ethiopia, with variation in risk associated with variation in rainfall, enhanced vegetation index, and altitude., (© The American Society of Tropical Medicine and Hygiene.)

Background: The World Health Organization (WHO), international donors and partners have emphasized the importance of integrated control of neglected tropical diseases (NTDs). Integrated mapping of NTDs is a first step for integrated planning of programmes, proper resource allocation and monitoring progress of control. Integrated mapping has several advantages over disease specific mapping by reducing costs and enabling co-endemic areas to be more precisely identified. We designed and conducted integrated mapping of lymphatic filariasis (LF) and podoconiosis in Ethiopia; here we present the methods, challenges and lessons learnt., Methods: Integrated mapping of 1315 communities across Ethiopia was accomplished within three months. Within these communities, 129,959 individuals provided blood samples that were tested for circulating Wuchereria bancrofti antigen using immunochromatographic card tests (ICT). Wb123 antibody tests were used to further establish exposure to LF in areas where at least one ICT positive individual was detected. A clinical algorithm was used to reliably diagnose podoconiosis by excluding other potential causes of lymphoedema of the lower limb., Results: A total of 8110 individuals with leg swelling were interviewed and underwent physical examination. Smartphones linked to a central database were used to collect data, which facilitated real-time data entry and reduced costs compared to traditional paper-based data collection approach; their inbuilt Geographic Positioning System (GPS) function enabled simultaneous capture of geographical coordinates. The integrated approach led to efficient use of resources and rapid mapping of an enormous geographical area and was well received by survey staff and collaborators. Mobile based technology can be used for such large scale studies in resource constrained settings such as Ethiopia, with minimal challenges., Conclusions: This was the first integrated mapping of podoconiosis and LF globally. Integrated mapping of podoconiosis and LF is feasible and, if properly planned, can be quickly achieved at nationwide scale.

Lymphatic filariasis is known to be endemic in Gambella Region, western Ethiopia, but the full extent of its endemicity in other regions is unknown. A national mapping program for Ethiopia was initiated in 2008. This report summarizes initial data on the prevalence of Wuchereria bancrofti antigenaemia based on surveys carried out in a sampled population of 11685 individuals living in 125 villages (112 districts) of western Ethiopia. The overall prevalence rate was 3.7%, but high geographical clustering and variation in prevalence (ranging from 0% to more than 50%) was found. The prevalence of hydrocele (in males) and lymphoedema of limbs was 0.8% and 3.6% respectively. Significantly higher (χ(2)=49.6; P<0.01) prevalence of antigenaemia was noted in known onchocerciasis endemic districts (4.7%) compared to non-onchocerciasis endemic districts (2.3%). Thirty-four of the 112 districts, with a population of 1547685 in 2007, were found to be endemic. Of these, the numbers of districts with prevalence rates of >20%, 10-20% and 5-9% were nine, 14 and 20 respectively. Twenty-nine of these 34 endemic districts were found in three regions: Gambella Region (seven districts), Beneshangul-Gumuz Region (13 districts), and Southern Nations, Nationalities and Peoples' Region (SNNPR) (nine districts). The other five were from Amhara (two districts) and Oromia (three districts) regions. A tentative distribution map has been drawn to facilitate the launching of the Ethiopia LF elimination program., (Copyright © 2011 Royal Society of Tropical Medicine and Hygiene. All rights reserved.)