A Five Year Trend Malaria Surveillance Data Analysis in Central, North and West Gondar Zones, Amhara Region, Northwest Ethiopia

Background : Trend analysis of malaria surveillance data is essential to inform stakeholders on progress towards malaria control. From the total 387,096 cases of malaria reported in Amhara region in 2017 G.C, 167,079 (43.2%) cases were in Central, North and West Gondar zones. From this total figure of zones, 15,445 (9.2%) were ≤5 years which contributes 4 % of cases in the region. So, the purpose of this study was to analyze trends of malaria parasite and districts of Central, North and West Gondar zones, Amhara Region, Northwest Ethiopia. Methods : A Retrospective study was conducted in Central, North and West Gondar zones from July 1- 30/ 2018. Data were collected, entered, cleaned, analyzed and interpreted using Microsoft Excel-2010. Different tables, figures and maps were used to present results. Result : A total of 2,827,722 cases have been received a diagnostic test of; Microscopy 1,712,193(60.56%) and Rapid Diagnostic Test (RDT) 1,115,529(39.44%). Trends of total patients treated as confirmed and clinical malaria cases in July 2017- June 2018 were decreased to 139297 (14%) as compared from July 2015- June 2016, 249571(25%). From total cases received diagnostic tests only 1,003,391 (36%) were confirmed and clinical cases treated with antimalaria. Of these Plasmodium falciparum and vivax malaria cases were confirmed to be 1,002,946 (99.96%) and clinical malaria cases were 445(0.04%), respectively. Conclusion : Risk of infection and diagnostic effort were high in West Gondar Zone. The Amhara public health institute including health Bureau, stakeholders and all responsible bodies should give special standing to highest malaria districts of West Gondar zone.


Introduction
Malaria is the most important parasitic and vector born disease caused by the four species African countries. There is complexity within countries, including large geographical variation incidence and differing upward or downward trends between indicators [3].
Ethiopia is one of the most malaria epidemic-prone countries in Africa [4]. The population is reaching 105,350,020 in July 2017. Sixty eight percent of the population is at risk of malaria [5]. Approximately 75% of the geographic regions have significant malaria transmission risk. Among the leading communicable disease in Ethiopia, malaria accounts for about 30% of the overall Disability Adjusted Life Years lost [4].
According to the objective of National Malaria Policies and Strategies of Ethiopia, PATH MACEPA, December 2015 report; by 2017 and beyond, 100% of suspected malaria cases are diagnosed using RDTs or microscopy within 24 hours of fever onset (4)(5)(6). From 2009 to 2013 a total estimate of 13 million confirmed and clinical cases of malaria were reported in Ethiopia. Amhara National Regional state is one of the Ethiopia Regions with total population of 23,442192 in 2017 estimate. The region consists of three major geographical zones, highlands or "Dega" ( beyond 2,300 meters above sea level), semihighlands or "Woyna Dega" (1,500 to 2,300 meters above sea level) and lowlands "Kolla" or hot climatic zones (below 1,500 meters above sea level) accounting 25 percent, 44 percent, and 31 percent respectively [6].
Early diagnosis and treatment of malaria reduces disease and prevents deaths. Stronger malaria surveillance systems are urgently needed to enable a timely and effective malaria response in endemic regions, to prevent outbreaks and resurgences, to track progress, and to hold governments and the global malaria community accountable [5]. The information also needed to prioritize the most affected areas by malaria in different years and months and also give information for further study. So, the purpose of this study was to describe a five years malaria trend of Central, North and West Gondar zones and its districts/ woreda's in Amhara region, Northwest Ethiopia.

Study setting
This study was conducted in Central, North and West Gondar zones of Amhara regional state. Amhara region is one of the low land malarious regions of Ethiopia. The regional state was made up of 13 administrative zones. Central, North and West Gondar Zones

Data Collection instrument
Secondary data collection checklist was prepared and used by reviewing the documented malaria surveillance data of weekly reported cases from Amhara Public health institute PHEM directorate office.

Data collection Process
Data was collected from APHI PHEM weekly malaria surveillance data. A regional weekly collected malaria data base was extracted to zones and woredas through filtering of important variables and filtered data were used for analysis. Total confirmed and clinically treated cases were cheeked as total inpatient and outpatient visited cases to have a quality data.

Data processing and Analysis
Data were entered, cleaned and analyzed into Microsoft office Excel 2010. A descriptive analysis, using mean and percentage was calculated. Different graphs and tables were used to present trends of malaria cases and total population. Maps were used to show study setting and malarious woredas Ethical Consideration Permission letter was gained from Amhara public health institute; research and technology transfer directorate; and permission letter was secured from APHI. The purposes and the importance of the study were explained to PHEM directorate. Confidentiality was assured at all levels of the study using password protected computer and through deleting all identifiers.

Operational Definition
Suspected malaria case: -Clinical diagnosis of malaria is made in a patient who has fever or history of fever in the last 48 hours and lives in malaria-endemic areas or has a history of travel within the last 30 days to malaria-endemic areas [7].   [9]. This may be due to geographical similarity of reported zones and woredas and similarity of study design.
Highest monthly Plasmodium falciparum transmission were observed in November with 24993(17%) cases followed by October 20873(14%) and September 16892(11%) cases respectively. Plasmodium vivax transmission were also high in November, October and September with 7365(14%), 5813(11%) and 5431(10%) cases respectively at Central, North and West Gondar zones. This result showed that a different study conducted in Sibu Sire District, East wolega zone, with a highest peak in June 18.9% followed by May, November, and July with prevalence rate, 13.3%, 13.2%, and 11.2%, respectively. The prevalence rate in October, August, and September were 9.4%, 8.7%, and 7%, respectively [10]. This study variation may be due to amount of rain fall, climatic variation, geographical difference and year of study.
From a total of 1,002, 946 confirmed malaria cases in Central, North and West Gondar zones; Plasmodium falciparum species were 736149 (73.4%) and plasmodium vivax were Kombolcha health center from January to December 2016, plasmodium falciparum accounted for 1243 (60.2%) while P. vivax accounted for 734 (35.5%) cases [11]. In this study PF in West and Central Gondar zone was the most frequently reported species. The reason for this variation is not clear; however, may be due to the previous study focus on health center and the current study cover zonal level and may need further study. (218/1000 population) were the leading woreda by Annual falciparum incidence. This result shows that a similar report to 167,079 (43.2%) cases of previous North Gondar Zone 2017 Health Bureau PHEM report [7]. This difference may be due to study period and study design variation and it also need further investigation.
Limitations of the study Plasmodium Falciparum and Vivax infection by pregnancy status, age categories and death of malaria with species infection were not analayzed. Distrbution of malaria by investement areas with its population at risk were not identified. Additionally, any malaria intervention activities that had been taken to control malaria were not collected from the study area. Confidentiality was assured at all levels of the study using password protected computer           Average annual blood examination rate, falciparum and test positivity rate in Central, North and West Gondar zones from July 2013-June 2018.