Entomological and Anthropological Factors Contributing to Persistent Malaria Transmission in Kenya, Ethiopia, and Cameroon.

INTRODUCTION: In order to improve our understanding of the fundamental limits of core interventions and guide efforts based on prioritization and identification of effective/novel interventions with great potentials to interrupt persistent malaria transmission in the context of high vector control coverage, the drivers of persistent disease transmission were investigated in three eco-epidemiological settings; forested areas in Cameroon, coastal area in Kenya and highland areas in Ethiopia. METHODS: Mosquitoes were sampled in three eco-epidemiological settings using different entomological sampling techniques and analysed for Plasmodium infection status and blood meal origin in blood-fed specimens. Human behavioural surveys were conducted to assess the knowledge and attitude of the population on malaria and preventive measures, their night activities, and sleeping pattern. The parasitological analysis was conducted to determine the prevalence of Plasmodium infection in the population using rapid diagnostic tests. RESULTS: Despite the diversity in the mosquito fauna, their biting behaviour was found to be closely associated to human behaviour in the three settings. People in Kenya and Ethiopia were found to be more exposed to mosquito bites during the early hours of the evening (18-21h) while it was in the early morning (4-6 am) in Cameroon. Malaria transmission was high in Cameroon compared to Kenya and Ethiopia with over 50% of the infected bites recorded outdoors. The non-users of LLINs were 2.5 to 3 times more likely to be exposed to the risk of acquiring malaria compared to LLINs users. Malaria prevalence was high (42%) in Cameroon, and more than half of the households visited had at least one individual infected with Plasmodium parasites. CONCLUSIONS: The study suggests high outdoor malaria transmission occurring in the three sites with however different determinants driving residual malaria transmission in these areas.

Analysis of asymptomatic and clinical malaria in urban and suburban settings of southwestern Ethiopia in the context of sustaining malaria control and approaching elimination.

BACKGROUND: Malaria intervention in Ethiopia has been strengthened significantly in the past decade. The Ethiopian government recently stratified the country based upon annual parasite incidence into malaria free, low, moderate and high transmission strata. Districts with low transmission were targeted for indigenous transmission elimination. Surveillance on malaria disease incidence is needed for planning control and elimination efforts. METHODS: Clinical malaria was monitored prospectively in health facilities in Jimma town, Oromia Region, southwestern Ethiopia from July 2014 to June 2015. Seasonal cross-sectional parasite prevalence surveys in local communities were conducted in 2014 and 2015 in eight kebeles. Case report forms were administered to obtain sociodemographic and epidemiological information from patients. RESULTS: A total of 1434 suspected malaria cases were examined from the health facilities and 428 confirmed malaria cases were found. Among them, 327 (76.4 %) cases were Plasmodium vivax, 97 (22.7 %) were Plasmodium falciparum, and 4 (0.9 %) were mixed infection of P. vivax and P. falciparum. The annual malaria incidence rate was 1.7 cases per 1000 people at risk. Parasite prevalence in the community was less than 3 %. Household ownership of insecticide-treated nets (ITNs) was 47.3 % (1173/2479) and ITN usage was 37.9 %. All ITNs were long-lasting insecticidal nets, and repellent use was not found in the study area. Being male and traveling were the significant risk factors for P. falciparum malaria. For P. vivax malaria, risk factors included occupation and history of malaria illness during the preceding 30 days. CONCLUSION: Epidemiological evidence suggested low clinical malaria incidence and prevalence in Jimma town. More aggressive measures may be needed to further suppress vivax transmission. Strategies should be planned targeting sustained control and elimination.

Molecular epidemiology of Plasmodium vivax and Plasmodium falciparum malaria among Duffy-positive and Duffy-negative populations in Ethiopia.

BACKGROUND: Malaria is the most prevalent communicable disease in Ethiopia, with 75% of the country's landmass classified as endemic for malaria. Accurate information on the distribution and clinical prevalence of Plasmodium vivax and Plasmodium falciparum malaria in endemic areas, as well as in Duffy-negative populations, is essential to develop integrated control strategies. METHODS: A total of 390 and 416 community and clinical samples, respectively, representing different localities and age groups across Ethiopia were examined. Malaria prevalence was estimated using nested PCR of the 18S rRNA region. Parasite gene copy number was measured by quantitative real-time PCR and compared between symptomatic and asymptomatic samples, as well as between children/adolescents and adults from the local community. An approximately 500-bp segment of the human DARC gene was amplified and sequenced to identify Duffy genotype at the -33rd nucleotide position for all the clinical and community samples. RESULTS: Plasmodium vivax prevalence was higher in the south while P. falciparum was higher in the north. The prevalence of P. vivax and P. falciparum malaria is the highest in children compared to adolescents and adults. Four P. vivax infections were detected among the Duffy-negative samples. Samples from asymptomatic individuals show a significantly lower parasite gene copy number than those from symptomatic infections for P. vivax and P. falciparum. CONCLUSIONS: Geographical and age differences influence the distribution of P. vivax and P. falciparum malaria in Ethiopia. These findings offer evidence-based guidelines in targeting malaria control efforts in the country.

Malaria incidence and assessment of entomological indices among resettled communities in Ethiopia: a longitudinal study.

BACKGROUND: Population resettlement has been considered among factors that may increase risk of malaria transmission. This study reports, the impact of resettlement on malaria incidence and entomological indices among communities resettled in suburbs of Jimma town, southwestern Ethiopia. METHODS: A cohort of 604 study participants (302 resettlers and 302 non-resettlers) was monthly followed-up from September to November 2013 using active case detection. Moreover, longitudinal entomological study was conducted from June to November 2013. Anopheline mosquitoes were collected using CDC light traps and pyrethrum spray catches. Sporozoite ELISA was performed to determine Plasmodium infection rates. RESULTS: Overall, 112 malaria cases were recorded during the three-month follow-up, of which 74.1% of the cases were from resettlement villages. Plasmodium falciparum incidence from resettlement and non-resettlement villages was 52.5 and 14.5/1,000 person-months at risk, respectively. Resettlement villages were three times at higher risk of Plasmodium infection (OR = 2.8, 95% CI: 1.22-6.48). Anopheles gambiae s.l. was the predominant (86.6%) of all the collected anopheline mosquito species. Plasmodium sporozoite rate in the resettlement and non-resettlement villages was 2.1 and 0.72%, respectively. Plasmodium falciparum entomological inoculation rate (EIR) for An. gambiae s.l. in the resettlement and non-resettlement villages was 13.1 and 0 infective bites/person/night, respectively. Both sporozoite rate and EIR were significantly higher in the resettlement villages (p < 0.05). CONCLUSION: Resettled communities were at higher risk of malaria infection as compared to non-resettled communities. Special attention should be given to malaria control interventions during resettlement programmes.

The effect of dams and seasons on malaria incidence and anopheles abundance in Ethiopia.

BACKGROUND: Reservoirs created by damming rivers are often believed to increase malaria incidence risk and/or stretch the period of malaria transmission. In this paper, we report the effects of a mega hydropower dam on P. falciparum malaria incidence in Ethiopia. METHODS: A longitudinal cohort study was conducted over a period of 2 years to determine Plasmodium falciparum malaria incidence among children less than 10 years of age living near a mega hydropower dam in Ethiopia. A total of 2080 children from 16 villages located at different distances from a hydropower dam were followed up from 2008 to 2010 using active detection of cases based on weekly house to house visits. Of this cohort of children, 951 (48.09%) were females and 1059 (51.91%) were males, with a median age of 5 years. Malaria vectors were simultaneously surveyed in all the 16 study villages. Frailty models were used to explore associations between time-to-malaria and potential risk factors, whereas, mixed-effects Poisson regression models were used to assess the effect of different covariates on anopheline abundance. RESULTS: Overall, 548 (26.86%) children experienced at least one clinical malaria episode during the follow up period with mean incidence rate of 14.26 cases/1000 child-months at risk (95% CI: 12.16 - 16.36). P. falciparum malaria incidence showed no statistically significant association with distance from the dam reservoir (p = 0.32). However, P. falciparum incidence varied significantly between seasons (p < 0.01). The malaria vector, Anopheles arabiensis, was however more abundant in villages nearer to the dam reservoir. CONCLUSIONS: P. falciparum malaria incidence dynamics were more influenced by seasonal drivers than by the dam reservoir itself. The findings could have implications in timing optimal malaria control interventions and in developing an early warning system in Ethiopia.

Enhancing Malaria Research, Surveillance, and Control in Endemic Areas of Kenya and Ethiopia.

Malaria control programs in Africa encounter daunting challenges that hinder progressive steps toward elimination of the disease. These challenges include widespread insecticide resistance in mosquito vectors, increasing outdoor malaria transmission, lack of vector surveillance and control tools suitable for outdoor biting vectors, weakness in malaria surveillance, and an inadequate number of skilled healthcare personnel. Ecological and epidemiological changes induced by environmental modifications resulting from water resource development projects pose additional barriers to malaria control. Cognizant of these challenges, our International Center of Excellence for Malaria Research (ICEMR) works in close collaboration with relevant government ministries and agencies to align its research efforts with the objectives and strategies of the national malaria control and elimination programs for the benefit of local communities. Our overall goal is to assess the impact of water resource development projects, shifting agricultural practices, and vector interventions on Plasmodium falciparum and P. vivax malaria in Kenya and Ethiopia. From 2017 to date, the ICEMR has advanced knowledge of malaria epidemiology, transmission, immunology, and pathogenesis, and developed tools to enhance vector surveillance and control, improved clinical malaria surveillance and diagnostic methods, and strengthened the capacity of local healthcare providers. Research findings from the ICEMR will inform health policy and strategic planning by ministries of health in their quest to sustain malaria control and achieve elimination goals.

The influence of the Gilgel-Gibe hydroelectric dam in Ethiopia on caregivers' knowledge, perceptions and health-seeking behaviour towards childhood malaria.

BACKGROUND: Malaria remains the most important public health problem in tropical and subtropical areas. Mothers' or caregivers' ability to recognize childhood malaria-related morbidity is crucial as knowledge, attitudes and health seeking behavior of caregivers towards childhood malaria could influence response to signs of the disease. METHODS: A total of 1,003 caregivers in 'at-risk' villages in close proximity to the Gilgel-Gibe hydroelectric dam in south-western Ethiopia, and 953 caregivers in 'control' villages further away from the dam were surveyed using structured questionnaires to assess their knowledge, perceptions and health seeking behaviour about childhood malaria. RESULTS: Malaria (busa) was ranked as the most serious health problem. Caregivers perceived childhood malaria as a preventable ('at-risk' 96%, 'control' 86%) and treatable ('at-risk' 98% and 'control' 96%) disease. Most caregivers correctly associated the typical clinical manifestations with malaria attacks. The use of insecticide-treated nets (ITNs) was mentioned as a personal protective measure, whereas the role of indoor residual spraying (IRS) in malaria prevention and control was under-recognized. Most of the caregivers would prefer to seek treatment in health-care services in the event of malaria and reported the use of recommended anti-malarials. CONCLUSION: Health education to improve knowledge, perceptions and health-seeking behaviour related to malaria is equally important for caregivers in 'at risk' villages and caregivers in 'control' villages as minimal differences seen between both groups. Concluding, there may be a need of more than one generation after the introduction of the dam before differences can be noticed. Secondly, differences in prevalence between 'control' and 'at-risk' villages may not be sufficient to influence knowledge and behaviour.

Sexual and Reproductive Health Services Use, Perceptions, and Barriers among Young People in Southwest Oromia, Ethiopia.

BACKGROUND: Utilizations of sexual and reproductive health (SRH) services among young people is vital in reducing sexual and reproductive health problems. This study investigated young people's perceptions and barriers towards the use of sexual and reproductive health services in Southwest Ethiopia. METHODS: A cross sectional study was employed to collect data from 1,262 in-school youths. Simple random sampling technique was used to select schools and study participants. Fifteen focus group discussions and 22 key informant interviews were conducted. Multiple logistic regression analyses were conducted. P value ≤ 0.05 was set to determine statistical significance. Data were analyzed using SPSS v16. Qualitative data were triangulated with quantitative findings and also presented in themes. RESULTS: Four hundred sixty (36.5%) of the respondents had utilized sexual and reproductive health services. Advice on sexual and reproductive health was the major (67.2%) service sought followed by seeking-treatments (23.3%). Health centers were the major (65.0%) source of SRH services. Being married, being sexually active, father-child communication, religion and place of residence were significantly associated with use of sexual and reproductive health services (p<0.05). Lack of information about SRH, poor perceptions about SRH, feeling of shame, fear of being seen by others, restrictive cultural norms, lack of privacy, confidentiality and unavailability of services were deterring use of sexual and reproductive health services. CONCLUSIONS: Only a small proportion of young people used sexual and reproductive health services. Hence, in addition to behavioral modification interventions, it is essential to consider multi-level and culturally sensitive interventions in a holistic approach.

Households willingness to pay for long-lasting insecticide treated nets in three urban communities of Assosa Zone, western Ethiopia.

BACKGROUND: Achieving the target coverage of insecticide treated nets (ITNs) has to be preceded by understanding their demands, willingness to pay (WTP) and determinants of WTP for those who could not get free of charge. OBJECTIVE: To assess WTP for long lasting ITN using contingent valuation method and determinants of maximum WTP for long lasting ITN among households in Assosa Zone, Western Ethiopia. METHODS: The contingent valuation method was used to assess WTP for long-lasting ITN among households selected from the three urban communities. univariate and multivariate regression analyses were carried out. The adjusted effect (beta), F-ratios, adjusted odds ratios (AOR) and 95% CI were used to interpret results. The criterion for statistical significance was set at 0.05. RESULTS: Ninety six percent of the respondents reported that long-lasting ITN are important for their family fbr prevention of malaria and demanded for long lasting ITN. Sixty seven percent of the respondents were willing to pay for long-lasting ITN at the starting bid amount of 25 Birr. The mean, maximum WTP amount was 27.84 Birr. The mean WTP amount varied with the respondents' wealth status, which was 19.09 and 35.26 Birr foir poorest and well-off wealth quintiles respectively. Wealth status and knowledge of the respondents about its preventive effects against boring insects were significantly associated with their WTP (adjusted beta = +3.76, 95% CI: 2.3, 4.6 and adjusted beta = 10.15, 95% CI: 2.7, 17.6 respectively). CONCLUSION: The poor have shown their WTP for reduced cost of ITN, thus the regional health bureau should develop a price discrimination mechanism for those economically vulnerable groups.

Transmission dynamics of co-endemic Plasmodium vivax and P. falciparum in Ethiopia and prevalence of antimalarial resistant genotypes.

Ethiopia is one of the few African countries where Plasmodium vivax is co-endemic with P. falciparum. Malaria transmission is seasonal and transmission intensity varies mainly by landscape and climate. Although the recent emergence of drug resistant parasites presents a major issue to malaria control in Ethiopia, little is known about the transmission pathways of parasite species and prevalence of resistant markers. This study used microsatellites to determine population diversity and gene flow patterns of P. falciparum (N = 226) and P. vivax (N = 205), as well as prevalence of drug resistant markers to infer the impact of gene flow and existing malaria treatment regimes. Plasmodium falciparum indicated a higher rate of polyclonal infections than P. vivax. Both species revealed moderate genetic diversity and similar population structure. Populations in the northern highlands were closely related to the eastern Rift Valley, but slightly distinct from the southern basin area. Gene flow via human migrations between the northern and eastern populations were frequent and mostly bidirectional. Landscape genetic analyses indicated that environmental heterogeneity and geographical distance did not constrain parasite gene flow. This may partly explain similar patterns of resistant marker prevalence. In P. falciparum, a high prevalence of mutant alleles was detected in codons related to chloroquine (pfcrt and pfmdr1) and sulfadoxine-pyrimethamine (pfdhps and pfdhfr) resistance. Over 60% of the samples showed pfmdr1 duplications. Nevertheless, no mutation was detected in pfK13 that relates to artemisinin resistance. In P. vivax, while sequences of pvcrt-o were highly conserved and less than 5% of the samples showed pvmdr duplications, over 50% of the samples had pvmdr1 976F mutation. It remains to be tested if this mutation relates to chloroquine resistance. Monitoring the extent of malaria spread and markers of drug resistance is imperative to inform policy for evidence-based antimalarial choice and interventions. To effectively reduce malaria burden in Ethiopia, control efforts should focus on seasonal migrant populations.

Mapping insecticide resistance and characterization of resistance mechanisms in Anopheles arabiensis (Diptera: Culicidae) in Ethiopia.

BACKGROUND: The emergence and spread of insecticide resistance in the major African malaria vectors Anopheles gambiae (s.s.) and An. arabiensis may compromise the current vector control interventions and threatens the global malaria control and elimination efforts. METHODS: Insecticide resistance was monitored in several study sites in Ethiopia from 2013 to 2015 using papers impregnated with discriminating concentrations of DDT, deltamethrin, bendiocarb, propoxur, malathion, fenitrothion and pirimiphos-methyl, following the WHO insecticide susceptibility test procedure. Mosquitoes sampled from different localities for WHO bioassay were morphologically identified as An. gambiae (s.l.) using standard taxonomic keys. Samples were identified to species using species-specific polymerase chain reaction (PCR) and screened for the presence of target site mutations L1014F, L1014S and N1575Y in the voltage gated sodium channel (VGSC) gene and G119S in the acethylcholinesterase (AChE) gene using allele-specific PCR. Biochemical assays were performed to assess elevated levels of acetylcholinesterases, carboxylcholinesterases, glutathione-S-transferases (GSTs) and cytochrome P450s monooxygenases in wild populations of An. arabiensis, compared to the fully susceptible Sekoru An. arabiensis laboratory strain. RESULTS: Populations of An. arabiensis were resistant to DDT and deltamethrin but were susceptible to fenitrothion in all the study sites. Reduced susceptibility to malathion, pirimiphos-methyl, propoxur and bendiocarb was observed in some of the study sites. Knockdown resistance (kdr L1014F) was detected in all mosquito populations with allele frequency ranging from 42 to 91%. Elevated levels of glutathione-S-transferases (GSTs) were detected in some of the mosquito populations. However, no elevated levels of monooxygenases and esterases were detected in any of the populations assessed. CONCLUSIONS: Anopheles arabiensis populations from all surveyed sites in Ethiopia exhibited resistance against DDT and pyrethroids. Moreover, some mosquito populations exhibited resistance to propoxur and possible resistance to bendiocarb. Target site mutation kdr L1014F was detected in all mosquito populations while elevated levels of glutathione-S-transferases (GSTs) was detected in some mosquito populations. The reduced susceptibility of An. arabiensis to propoxur and bendiocarb, which are currently used for indoor residual spraying (IRS) in Ethiopia, calls for continuous resistance monitoring, in order to plan and implement evidence based insecticide resistance management.

Household satisfaction with a community-based health insurance scheme in Ethiopia.

BACKGROUND: Community-based health insurance (CBHI) schemes are an emerging tool for providing financial protection against health-related poverty. In Ethiopia, CBHI is being piloted in 13 districts, but community experience and satisfaction with the scheme have yet to be studied. Therefore, this study aimed to assess the experiences and satisfaction of households enrolled in a pilot CBHI scheme. METHODS: A community-based cross-sectional study method was used in one pilot district in South Ethiopia. Data were collected in March and April 2014. 386 households enrolled in the CBHI scheme were sampled by simple random sampling. Data were collected by trained data collectors using a pre-tested structured questionnaire. Descriptive statistics and bivariate and multiple linear regression analyses were performed. P values less than 0.05 and 95 % confidence intervals were used to determine associations between independent and dependent variables. RESULTS: The study revealed that overall household satisfaction with CBHI was 91.38 %. Moreover, there was a significant association between health service provision and CBHI members' satisfaction scores. For instance, household heads that strongly disagreed with laboratory services provision had an average 0.878 decrease in CBHI satisfaction score compared to household heads that strongly agreed. CBHI process- and management-related factors were also significantly associated with satisfaction. CONCLUSIONS: Satisfaction with CBHI was high. Age, family size, laboratory services provision, health services provider friendliness, CBHI offices opening times, membership card collection process, and time interval to use of services were significant predictors of satisfaction with CBHI.

Pharmaceutical Regulatory Framework in Ethiopia: A Critical Evaluation of Its Legal Basis and Implementation.

BACKGROUND: Effective and enforceable national regulations describing the manufacture and (re)packaging, export and import, distribution and storage, supply and sale, information and pharmaco-vigilance of medicines are required to consistently ensure optimal patient benefit. Expansion of pharmaceutical industries in many countries with advancement in transport technologies facilitated not only trade of genuine pharmaceutical products but also the circulation of poor quality medicines across the globe. In Ethiopia, even though "The Pharmacists and Druggists Proclamation No 43/1942" was used to regulate both the professions and the facilities where they were practiced, comprehensive regulation of the pharmaceutical market was introduced in 1964 by a regulation called "Pharmacy Regulation No. 288/ 1964". This legislation formed the legal basis for official establishment of drug regulation in the history of Ethiopia, enabling the regulation of the practice of pharmacists, druggists and pharmacy technicians; manufacturing, distribution, and sale of medicines. In June 1999, a new regulation called the "Drug Administration and Control Proclamation No. 176/1999" repealed most parts of the regulation 288/1964. The law established an independent Drug Administration and Control Authority (DACA) with further mandate of setting standards of competence for licensing institutions/facilities. DACA was re-structured as Food, Medicine and Health Care Administration and Control Authority (EFMHACA) of Ethiopia by the "Proclamation No. 661/2009" in 2010 bearing additional responsibilities like regulation of food, health care personnel and settings. The mere existence of this legal framework does not guarantee complete absence of illegal, substandard and falsified products as well as illegal establishments in the pharmaceutical chain. Therefore, the objective of the research is to assess the pharmaceutical regulatory system in Ethiopia and to reveal possible reasons for deficiencies in the pharmaceutical chain. METHODS: An archival review, an in-depth interview of key informants and an institutions-based cross-sectional survey study were conducted during March to April 2013. The comprehensiveness of the pharmaceutical law to protect public health relative to three selected African countries (South Africa, Tanzania and Uganda) and European Union, and implementation was assessed. RESULTS: The study revealed that Ethiopia does have a written national drug policy upon which the Medicines Regulatory Proclamation 661/2009 is based. According to this proclamation, the Ethiopian The Food, Medicines and Healthcare Administration and Control Authority is mandated to execute the regulatory activities as per the council of ministers regulation 189/2010. The legal framework for pharmaceutical regulation of Ethiopia was founded to fulfill all the medicines regulatory functions potentially enabling to combat illegal, substandard and falsified medicines and illegal establishments. Moreover, all the key informants witnessed that the government is commited and proclamation 661/2009 is comprehensive, but they stressed the compelling need of regulatory tools for effective implementation. From the institution-based cross-sectional study, it was revealed that there exist illegal sources formedicine in the pharmaceutical market. The main reasons for their existence were regulatory factors including weak regulatory enforcement (64.5%), lack of informal market control (60.8%), weak port control (50.0%), and poor cooperation between executive bodies (39.6%); and resource constraint (27.8%), which is an institutional factor. CONCLUSIONS: From legislative point of view, the medicines regulatory framework in Ethiopia fulfils all regulatory functions required for effective medicines regulation. However, the existence of the legislation by its own is not a guarantee to prevent the existence of unauthorized/illegal medicine sources since this requires effective implementation of the legislation, which is in fact affected by the governments political commitment, resource and intergovernmental cooperation.

The Role of Empowerment in the Association between a Woman's Educational Status and Infant Mortality in Ethiopia: Secondary Analysis of Demographic and Health Surveys.

BACKGROUND: Socioeconomic status at national, sub-national, household, and individual levels explains a significant portion of variation in infant mortality. Women's education is among the major determinants of infant mortality. The mechanism through which a woman's own educational status, over her husband's as well as household characteristics, influences infant mortality has not been well studied in developing countries. The objective of this study was to explore the role of woman's empowerment and household wealth in the association between a woman's educational status and infant mortality. METHODS: The association between a woman's educational status and infant death, and the role of woman's empowerment and household wealth in this relationship, were examined among married women in Ethiopia through a secondary, serial cross-sectional analysis utilizing data on birth history of married women from three rounds of the Ethiopian Demographic and Health Survey. Univariate, bivariate, and multivariate analyses were conducted to examine the association between woman's education and infant death, and the possible mediation or moderation roles of woman empowerment and household wealth. RESULTS: Female education and empowerment were inversely associated with infant death. The results indicated mediation by empowerment in the education-infant death association, and effect modification by household wealth. Both empowerment and education had strongest inverse association with infant death among women from the richest households. CONCLUSION: The findings suggest an important role of female empowerment in the education-infant death relation, and the complexity of these factors according to household wealth. Woman empowerment programs may prove effective as a shorter term intervention in reducing infant mortality.

Bio-efficacy of selected long-lasting insecticidal nets against pyrethroid resistant Anopheles arabiensis from South-Western Ethiopia.

BACKGROUND: The emergence and spread of insecticide resistance in the major African malaria vectors Anopheles gambiae s.s. and Anopheles arabiensis may compromise control initiatives based on insecticide-treated nets (ITNs) or indoor residual spraying (IRS), and thus threaten the global malaria elimination strategy. METHODS: We investigated pyrethroid resistance in four populations of An. arabiensis from south-western Ethiopia and then assessed the bio-efficacy of six World Health Organization recommended long lasting insecticidal nets (LLINs) using these populations. RESULTS: For all four populations of An. arabiensis, bottle bioassays indicated low to moderate susceptibility to deltamethrin (mortality at 30 minutes ranged between 43 and 80%) and permethrin (mortality ranged between 16 and 76%). Pre-exposure to the synergist piperonylbutoxide (PBO) significantly increased the susceptibility of all four populations to both deltamethrin (mortality increased between 15.3 and 56.8%) and permethrin (mortality increased between 11.6 and 58.1%), indicating the possible involvement of metabolic resistance in addition to the previously identified kdr mutations. There was reduced susceptibility of all four An. arabiensis populations to the five standard LLINs tested (maximum mortality 81.1%; minimum mortality 13.9%). Bio-efficacy against the four populations varied by net type, with the largest margin of difference observed with the Jimma population (67.2% difference). Moreover, there were differences in the bio-efficacy of each individual standard LLIN against the four mosquito populations; for example there was a difference of 40% in mortality of Yorkool against two populations. Results from standard LLINs indicated reduced susceptibility to new, unused nets that was likely due to observed pyrethroid resistance. The roof of the combination LLIN performed optimally (100% mortality) against all the four populations of An. arabiensis, indicating that observed reductions in susceptibility could be ameliorated with the combination of PBO with deltamethrin, as used in PermaNet® 3.0. CONCLUSION: Our results suggest that bio-efficacy evaluations using local mosquito populations should be conducted where possible to make evidence-based decisions on the most suitable control products, and that those combining multiple chemicals such as PBO and deltamethrin should be considered for maintaining a high level of efficacy in vector control programmes.

Private hospital sector development: an exploratory study on providers perspective in addis ababa, ethiopia.

BACKGROUND: Over the past decade there is a trend of fast development in the private hospital sector in Ethiopia. This important component of the health care system has received policy attention and federal government is a promoter for private health care. Yet lack of basic data on the factors affecting the growth of private health care provision in the country and no studies are available on this issue in Ethiopia. The aim of this study is to get some preliminary insights on the factors affecting the growth and development of private hospital sector in Addis Ababa, Ethiopia with perspective of provider. METHODS: A hospital based qualitative study was conducted in 25 for-profit hospitals in Addis Ababa using key informant in-depth interviews and secondary data was collected from Federal Ministry of Health and Addis Ababa City Health Administration and private hospital providers. RESULTS: The findings of the study suggest that private hospital sector is expanding significantly in recent years in Ethiopia. The active role of government is a catalyst for the growth of private facilities in the country. Factors outside the health are growing disposable income, improvements in literacy, road networks, population growth and long standing diseases, all contribute to the trend. But private providers are facing many problems, like availability of trained manpower, escalation of costs, availability and quality of drugs and financing mechanisms. CONCLUSION: Private hospital sector is expanding in Ethiopia. But private providers are vulnerable to imperfections in the existing market structure. Government and professional bodies need to make a concerted effort to address these issues and design appropriate strategies to promote and regulate this sector effectively.

Health workforce deployment, attrition and density in East wollega zone, Western ethiopia.

BACKGROUND: In East Wollega Zone, despite the success in creating considerable number of health facilities, short-age of health personnel, geographical imbalance and increasing attrition is found to be a persistent barrier to the effectiveness of the health system. However, available data is not rich enough to provide reliable information as to what extent these problems exist in the Zone. Hence, this study was conducted to assess health workforce density, deployment and attrition in East Wollega Zone. METHODS: A six years retrospective record review from 2000-2005 was conducted between February 1, and March 30, 2006 in eleven randomly selected districts of East Wollega Zone. Data obtained from records and interviews made with selected resource persons were organized by triangulating quantitatively and qualitatively. Quantitative data was analyzed using SPSS 12.01 for windows and thematic frame work analysis was used for qualitative data. RESULTS: Health workforce deployment rate for the years 2000-2005 ranged from 8.2% to 15.4 %. In contrast, attrition rate for the same period ranged from 2.9 % to 8.5 %. Attrition rate for the time after decentralization (2003-2005) was nearly two times greater than before decentralization (OR, 2.04, CI, 1.51, 2.85, P=0.00). Moreover, attrition rate was nearly three times greater for a high level professional when compared to the lower level (OR, 3.15, CI , 2.63, 4.37, P=0.00). Attrition rate for males was two times higher as compared to females (OR, 2.07, CI, 1.67, 3.74, P=0.00). About (26.3%) of all health workers and (36.7%) of nurses and midwives were deployed to the capital town of the zone. Factors identified as most likely cause for the lower deployment and higher attritions were budget related constraints, lack of continuing education opportunity and poor career development. CONCLUSIONS: The number of health personnel in East Wollega was low both by international standards and relative to the national density. Moreover, attrition was higher for the time after decentralization process. Hence, measures that seek to increase the size of the health workforce through increased recruitment, higher retention of existing staff and better geographical balance have to be urgently explored.