The epidemiology of highland malaria in Ethiopia: a study from Butajira area

On May 30th, 2013, Adugna Woyessa defended his PhD thesis at Addis Ababa University. The PhD thesis The epidemiology of highland malaria in Ethiopia: a study from Butajira area aims to  describe human malaria transmission  in rural south central Ethiopian highlands.


Background:In Ethiopia, malaria is a major public health problem with seasonal and unstable distribution. Because of the country’s diverse topography and climate, transmission of malaria varies with space and time; while the variability is more pronounced in highlands with low transmission. This calls for better understanding of malaria. However, there is paucity of information on magnitudeof malaria, risk factors, effective use of vector control measures such as insecticide-treated nets in relationship with malaria infection and performance of multi-species detecting malaria rapid diagnostic tests (RDTs) where Plasmodium falciparum and Plasmodium vivax co-exist at highlands of low-endemicity.

Objectives:To describe the epidemiology of highland malaria with emphasis to the magnitude and associated factors as well as interventions in various altitudesof Butajira area, south-central Ethiopia.

METHODS: Community-based repeated cross-sectional studies were conducted in six rural kebeles of Meskan and Mareko Districts from October 2008 to June 2010in Butajira area, Ethiopia. The kebeles (Hobe, Bati Lejano, Dirama, Shershera Bido, Yeteker and Wurib) were selected in such a way that two were from one altitudinal stratum thus making a total of three strata: low (1,800-1,899 meters above sea level), mid-level (1,900-1,999 meters above sea level), and high (2,000-2,300 meters above sea level) altitudes. These kebeles are part of Demographic Surveillance System Site of the Butajira Rural Health Program). A multi-stage sampling method was used to recruit study participants. The various stages were kebeles as first-stage, villages as second-stage, and households as third-stage units.   A total of 3,393 individuals were recruited from randomly sampled 750 households in 16 villages. Probability proportion to size sampling method was applied to allocate the number of households to be sampled from each kebeleand village. The study obtained data from household interview, survey and recruiting all self-reported febrile cases.  Household interview was undertaken by trained data collectors using pre-tested structured questionnaire. Household altitude reading and geo-reference was recorded from geographical positioning system location. Seasonal blood surveys were made on quarterly basis between Oct. 2008 and Jun. 2010. From the sampled households, all family members who consented to participate were requested for blood films. Besides, self-reported febrile cases were simultaneously checked for malaria infection using RDTs. CareStartTMMalaria Plasmodium falciparum/ Plasmodium vivax combo test result was compared with microscopy. Analytical tools including descriptive statistics, multilevel analysis, principal component analysis, and complex sample analysis were employed.

Main findings: The unadjusted prevalence of malaria was found to be 0.93 % [95% CI 0.79-1.07]; of 19, 207 people, 178 were positive; adjusted prevalence of malaria was estimated at 0.78 (95% CI: 0.48-1.29); of 19, 199 people, 178 were positive. Plasmodium vivax was dominant (86.5%, n=154) and the rest of the cases were due to Plasmodium falciparum (12.4%, n=22, seven with gametocyte) and mixed infections (1.1%, n=2).The prevalence varied among villages with the highest prevalence of 2.8% in Dadesso and Horosso villages (both <1,850 masl), and the lowest prevalence of 0.0% in Sunke Wenz and Akababi village (2,100-2,180 masl). Malaria prevalence decreased with altitude: 1.91% [95% CI (1.55-2.27)] in low, 1.37% [95% CI (0.87-1.87)] in mid-level and 0.36% [95% CI (0.25-0.47)] in high altitude zones; the highest prevalence was found at low altitude between October and November 2009. Moreover, malaria varied among age groups and the variation was different at different at altitudes. It reached its peak in children aged one to four yearsYonkers at mid-level and one to nine years at low altitudes. However, its prevalence at higher altitude was low and was similar across all age groups. Plasmodium falciparum malaria occurred rarely throughout the survey periods, with relatively more cases in October-November 2009 in the low altitude zone. Plasmodium vivax was found in all survey periods. However, its prevalence differed with respect to survey period and altitude. Variables like age (children aged below five and 5-9 years), altitude (low and mid-level altitude), and in houses with holes as individual-level factors; and village-level variables explained most of the variation (ICC= 94%) in individual malaria infection. The estimates of village-level variances showed well marked differences in malaria infection.

Only 28.5% [95%CI 25.8-31.4] of the 739 households surveyed owned at least an ITN.  Household ITN ownership was associated with household heads with no formal education, male-headed households, more beds in the house, absence of mosquito source reduction, and nonexistence of main water body. Male-headed households were also more associated with increased ITN ownership than female-headed ones. Households with ITN observed hanging, two and more number of ITN owned, not doing source reduction and less than a kilometredistance from main water body showed high association with use of ITN while the presence of more ITN observed hanging was a good predictor. Higher prevalence was found among people surveyed from ITN-owning than non-ITN-owning households (2.1% versus 0.5%). Malaria infection was more often observed in households owning at least an ITN than in their counterparts (unadjusted OR 4.1 [95% C.I. 2.2-7.6]; F (1, 22) =25.2, P<0.001).

Data obtained from a total of 2,394 self-reported febrile cases: 66.8% (n=1,598) from health facilities and the rest 33.2% (n=796) from surveys. Higher proportionof Plasmodium positives and both Plasmodium falciparum and Plasmodium vivaxwere detected at health facilities compared to what was seen in the survey. However, more mixed infections were observed in the latter. Low sensitivity of the test was observed in all Plasmodium species (90.8%, 95% CI: 82.9-95.3), and Plasmodium falciparum (87.5%, 52.9-97.8) in survey; and Plasmodium vivax (92.8%, 95% CI: 89.3-95.2) at health facilities. Low specificity of Plasmodium vivax (87.5%, 95% CI: 52.9-97.8) was found at the survey and all Plasmodium species (82.7%, 95% CI: 80.5-84.8) at health facilities. Very low PPV was detected in all Plasmodium species (76.7%, 95% CI: 67.7-83.8), and Plasmodium falciparum (87.5%, 95% CI: 52.9-97.8) at the survey and all Plasmodium species (64.3%, 95% CI: 60.5-68.1) and Plasmodium falciparum (77.2%, 95% CI: 67.6-84.5) at health facilities.  Low NPV was observed in Plasmodium vivax both in the survey (87.5%, 95% CI: 52.9-97.8) and health facilities (77.2: 67.6-84.5).The measure of agreement or kappa score was almost perfect agreement in all categories, except in all Plasmodium species with substantial agreement.

Conclusions and recommendations: This thesis demonstrates that low prevalence of malaria with age and altitude dependent distribution was found in highlands with low transmission in south-central Ethiopia. Plasmodium vivax was the dominant species more prevalent throughout the survey. There was very low ITN use that might have also hardly protected children in ITN-owning households. Performance of malaria RDT detecting Plasmodium falciparum and Plasmodium vivax vary between health facility-based and survey setting for both species. A malaria intervention that prioritises children below 10 years appears to be practically feasible to reduce malaria transmission. Strengthening surveillance to help in evidence-informed decision of vector control is recommendable. Furthermore, future studies should target designing more frequent survey and application of PCR for evaluation of RDT performance.


Woyessa A, Deressa W, Ali A, Lindtjorn B. Ownership and use of long-lasting insecticidal nets for malaria prevention in Butajira area, south-central Ethiopia: complex samples data analysis. BMC public health 2014; 14: 99.

Woyessa A, Deressa W, Ali A, Lindtjørn B. Evaluation of CareStartTM malaria Pf/Pv combo test for Plasmodium falciparum and Plasmodium vivax malaria diagnosis in Butajira area, south-central Ethiopia. Malaria Journal 2013, 12:218 doi:10.1186/1475-2875-12-218

Woyessa A, Deressa W, Ali A, Lindtjørn B. Malaria risk factors in Butajira area, south-central Ethiopia: a multilevel analysis. Malaria Journal 2013, 12:273. 

Woyessa A, Deressa W, Ali A, Lindtjørn B. Prevalence of malaria infection in Butajira area, south-central Ethiopia. Malaria Journal 2012, 11:84

The full-text thesis can be downloaded here. 

Reducing maternal deaths in Southwest Ethiopia

Lindtjørn B, Mitiku D, Zidda Z, Yaya Y (2017) Reducing Maternal Deaths in Ethiopia: Results of an Intervention Programme in Southwest Ethiopia. PLoS ONE 12(1): e0169304. doi:10.1371/journal.pone.0169304

Background  In a large population in Southwest Ethiopia (population 700,000), we carried out a complex set of interventions with the aim of reducing maternal mortality. This study evaluated the effects of several coordinated interventions to help improve effective coverage and reduce maternal deaths. Together with the Ministry of Health in Ethiopia, we designed a project to strengthen the health-care system. A particular emphasis was given to upgrade existing institutions so that they could carry out Basic (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC). Health institutions were upgraded by training non-clinical physicians and midwives by providing the institutions with essential and basic equipment, and by regular monitoring and supervision by staff competent in emergency obstetric work.

Results  In this implementation study, the maternal mortality ratio (MMR) was the primary outcome. The study was carried out from 2010 to 2013 in three districts, and we registered 38,312 births. The MMR declined by 64% during the intervention period from 477 to 219 deaths per 100,000 live births (OR 0.46; 95% CI 0.24–0.88). The decline in MMR was higher for the districts with CEmOC, while the mean number of antenatal visits for each woman was 2.6 (Inter Quartile Range 2–4). The percentage of pregnant women who attended four or more antenatal controls increased by 20%, with the number of women who delivered at home declining by 10.5% (P<0.001). Similarly, the number of deliveries at health posts, health centres and hospitals increased, and we observed a decline in the use of traditional birth attendants. Households living near to all-weather roads had lower maternal mortality rates (MMR 220) compared with households without roads (MMR 598; OR 2.72 (95% CI 1.61–4.61)).

Conclusions  Our results show that it is possible to achieve substantial reductions in maternal mortality rates over a short period of time if the effective coverage of well-known interventions is implemented.

Joint PhD Programme

Joint-PhDs are doctorates, which are done at two degree-awarding institutions. This doctorate means that you are fully registered in two universities, having to comply with admission requirements, and assessment regulations at both institutions, and it will result in one jointly awarded PhD (one diploma with the two university logos).

The other benefits for students are:

  • Access to complementary facilities and resources
  • Exposure to two cultural approaches to research
  • International student mobility
  • Enhanced acquisition of research and transferable skills, such as negotiation skills, use of videoconferencing, adaptability…
  • Better networking opportunities

Recently, Hawassa University and the University of Bergen agreed on such a joint PhD degree.

This programme is funded by The South Ethiopia Network of Universities in Public Health (SENUPH), and nine PhD students have been registered at the home institution which in this case is Hawassa University. The currently available financial support is for staff at Hawassa, Dilla and Wolaita Sodo universities. We plan to admit seven more students (four women and three men) in September 2016.

You can get more information about the admission requirements and about topics that this programme will prioritise by writing to Dr Eskindir Loha or to Professor Bernt Lindtjørn.

The structure of the joint PhD programme can be downloaded here.

Yalio Yaya defends his PhD thesis

Yaliso-front-pageThe overall objective of the PhD thesis is to measure and compare maternal and neonatal mortality and obstetric services through community- and facility-based methods in southern Ethiopia. Yaliso Yaya used four different methods to measure maternal mortality:

  1. A prospective community-based birth registry managed by health extension workers in 75 rural villages in three districts in south Ethiopia (population 421 639)
  2. A household survey conducted in 6 572 households in 15 randomly selected rural villages in the district of Bonke, with questions about pregnancy and birth outcomes in the last five years
  3. A household survey among 8 503 adult siblings using the sisterhood method
  4. A facility-based review of records in all 63 health centres and three hospitals in Gamo Gofa zone.

Neonatal mortality was measured with the second method, and emergency obstetric services were assessed through the facility-based review.

The thesis is based on a thorough and systematic registration of adverse events during several years, using multiple methods. This allows validation of estimates, and it presents detailed and precise information about maternal mortality rates from rural south Ethiopia.

A special focus of the work is on the finding that community based health workers (Health Extension Workers) can be used to generate maternal mortality data, thus alleviating the chronic problem of unavailability of valid and timely mortality data.

The PhD thesis can be downloaded here.

Measuring maternal mortality

Yaya Y, Data T, Lindtjørn B (2015) Maternal Mortality in Rural South Ethiopia: Outcomes of Community-Based Birth Registration by Health Extension Workers.PLoS ONE 10(3): e0119321. doi: 10.1371/journal.pone.0119321

Rural communities in low-income countries lack vital registrations to track birth outcomes. We aimed to examine the feasibility of community-based birth registration and measure maternal mortality ratio (MMR) in rural south Ethiopia.

In 2010, health extension workers (HEWs) registered births and maternal deaths among 421,639 people in three districts (Derashe, Bonke, and Arba Minch Zuria). One nurse-supervisor per district provided administrative and technical support to HEWs. The primary outcomes were the feasibility of registration of a high proportion of births and measuring MMR. The secondary outcome was the proportion of skilled birth attendance. We validated the completeness of the registry and the MMR by conducting a house-to-house survey in 15 randomly selected villages in Bonke.

We registered 10,987 births (81·4% of expected 13,492 births) with annual crude birth rate of 32 per 1,000 population. The validation study showed that, of 2,401 births occurred in the surveyed households within eight months of the initiation of the registry, 71·6% (1,718) were registered with similar MMRs (474 vs. 439) between the registered and unregistered births. Overall, we recorded 53 maternal deaths; MMR was 489 per 100,000 live births and 83% (44 of 53 maternal deaths) occurred at home. Ninety percent (9,863 births) were at home, 4% (430) at health posts, 2·5% (282) at health centres, and 3·5% (412) in hospitals. MMR increased if: the male partners were illiterate (609 vs. 346; p= 0·051) and the villages had no road access (946 vs. 410; p= 0·039). The validation helped to increase the registration coverage by 10% through feedback discussions.

It is possible to obtain a high-coverage birth registration and measure MMR in rural communities where a functional system of community health workers exists. The MMR was high in rural south Ethiopia and most births and maternal deaths occurred at home.

New master thesis on patient satisfaction at delivery services

Rahel Tesfaye.Client Satisfaction with Delivery Care Services and Associated Factors in the Public Health Facility of Gamo Gofa Zone, South West Ethiopia. 2014. Arba Minch University and Addis Continental Institute of Public Health.

Background Ensuring patient satisfaction is an important means of secondary prevention of maternal mortality. Satisfied women may be more likely to follow to health providers’ recommendations. And, studying patient satisfaction can help to improve services, and reduce costs. However, so far there few reports on client satisfaction on delivery care from developing countries. This study presents findings from a multi-dimensional study of client satisfaction from the Gamo Gofa Zone in South-West Ethiopia.

Objective The aim of this study was to assess how satisfied clients using delivery services at public health facilities are Gamo Gofa zone in South-West Ethiopia.

Methods Using exit interviews and we did a facility based cross sectional study in December 2013 and January 2014. We measured client satisfaction using a survey adopted from the Donabedian quality assessment framework. We randomly sampled 13 of 66 institutions in Gamo Gofa. The number of delivering mothers in each health institution was based on proportional to size allocation. We used logistic regression to determine predictors of client satisfaction.

Results Most of mothers (79%; 95% CI; 75-82%) were satisfied with delivery care. The presence of support persons during child birth improved satisfaction (AOR=8.19 95% CI; 3.49-18.8). ), as were women who delivered with caesarean section (AOR 2.99; 95% CI; 1.17 -7.66). However, client satisfaction was reduced if the women had to pay for the services (AOR=0.13 95%CI; 0.06-0.29). Women attending hospitals were less satisfied (69%) than women attending health centres (94%). The proportion of women who complained about an unfriendly attitude from health workers was higher in the hospitals.

Conclusions The study shows that that overall satisfaction level good, but there is room for improvements. More emphasis should be to have women friendly care, especially at the hospitals

Diriba Korecha Dadi’s PhD on Predicting Seasonal Climate in Ethiopia

On April 25, 2014 Diriba Korecha Dadi defended his PhD at the University of Bergen. Diriba was a part of the research programme “Ethiopian Malaria Prediction System”.

The Abstract of the thesis is found at:

His thesis, Characterizing the Predictability of Seasonal Climate in Ethiopia, can be downloaded

New Article: Trends in TB case notification over fifteen years in Arsi in Ethiopia

Hamusse SD, Demissie M, Lindtjorn B. Trends in TB case notification over fifteen years: the case notification of 25 Districts of Arsi Zone of Oromia Regional State, Central Ethiopia. BMC public health 2014; 14(1): 304.

Background  The aims of tuberculosis (TB) control programme are to detect TB cases and treat them to disrupt transmission, decrease mortality and avert the emergence of drug resistance. In 1992, DOTS strategy was started in Arsi zone and since 1997 it has been fully implemented. However, its impact has not been assessed. The aim of this study was, to analyze the trends in TB case notification and make a comparison among the 25 districts of the zone.

Methods  A total of 41,965 TB patients registered for treatment in the study area between 1997 and 2011 were included in the study. Data on demographic characteristics, treatment unit, year of treatment and disease category were collected for each patient from the TB Unit Registers.

Results  The trends in all forms of TB and smear positive pulmonary TB (PTB+) case notification increased from 14.3 to 150 per 100,000 population, with an increment of 90.4% in fifteen years. Similarly, PTB+ case notification increased from 6.9 to 63 per 100,000 population, an increment of 89% in fifteen years. The fifteen-year average TB case notification of all forms varied from 60.2 to 636 (95% CI: 97 to 127, P<0.001) and PTB+ from 10.9 to 163 per 100,000 population (95% CI: 39 to 71, p<0.001) in the 25 districts of the zone. Rural residence (AOR, 0.23; 95% CI: 0.21 to 0.26) and districts with population ratio to DOTS sites of more than 25,000 population (AOR, 0.40; 95% CI: 0.35 to 0.46) were associated with low TB case notification. TB case notifications were significantly more common among 15-24 years of age (AOR, 1.19; 95% CI:1.03 to 1.38), PTB- (AOR, 1.46; 95% CI: 1.33 to 64) and EPTB (AOR, 1.49; 95% CI; 1.33 to 1.60) TB cases.

Conclusions  The introduction and expansion of DOTS in Arsi zone has improved the overall TB case notification. However, there is inequality in TB case notification across 25 districts of the zone. Further research is, recommended on the prevalence, incidence of TB and TB treatment outcome to see the differences in TB distribution and performance of DOTS in treatment outcomes among the districts.

Detecting P. falciparum and P. vivax

This paper reviews the sensitivity and specificity of RDTs for detecting P. falciparum and P. vivax in two different settings ¿ at health centres and in a household survey. The study includes a large number of patients (2,394 participants) and provides useful additional information about the performance of these RDTs.

Woyessa A, Deressa W, Ali A, Lindtjørn B. Evaluation of CareStartTM malaria Pf/Pv combo test for Plasmodium falciparum and Plasmodium vivax malaria diagnosis in Butajira area, south-central Ethiopia. Malaria Journal 2013, 12:218 doi:10.1186/1475-2875-12-218