Trends of Malaria on Hotspot and Ivermectin Mass-drug Administration Zone of Amhara Regional State, 2020


 Background:- Public health surveillance (PHS) is the continuing organized gathering, investigation, elucidation, and well-timed distribution of health-related information for activities and program evaluation. Conducting a surveillance system evaluation is crucial for monitoring the efficacy and effectiveness of intervention programs in health care systems. This study aimed to Evaluate the Trends of Malaria in the hotspot and Ivermectin mass-drug administration Zone of Amhara Regional State, Ethiopia, 2020.Methods: - A descriptive prevalence study design was used to evaluate the surveillance system of the Awi zone selected woreda. 25 study sources were incorporated in the survey (5 District Health Offices (5HOs), 10 Health Centers (10HCs), and 10 Health Posts (10 HPs). Purposive sampling techniques were utilized. Data were obtained by communicable diseases control the standard format of systematic evaluation of four surveillance units from January to August 2020 through observation, document review, and interviewing surveillance officers and focal persons using a semi-structured Survey.Results: - Average report fullness and aptness were 97.9% and 96% respectively. The average annual malaria incidence rate was a decline from the year 2015 to 2019 with an average reduction rate of 5.5% and the average annual parasitic incidence rate was 52 (22-199). In 2019/2020, 43131 Malaria cases were reported in the zone. Supervisions were made as integrated supportive supervision in the last six months. However, there was no program specific supportive supervision of public health emergency management. Data analysis was not routinely practiced in both visited districts and was not used for decision making.Conclusions: This result revealed that the malaria incidence rate showed a remarkable decline. However, the annual parasitic incidence rate remains constant. This indicates that ivermectin did not affect malaria elimination. The structure of the surveillance information transfer as of Kebel to Zone was well organized. However, coordination and supervision of the surveillanc activities were not frequent. From those supervised health facilities, most of them are not receiving feedback. There was no budget line, written feedback, epidemic and preparedness, and a response plan regular based on supportive supervision at all visited health facilities. Depending on this, we recommend that districts and sub-city health offices should conduct regular surveillance data analysis, perform supportive supervision, avail budgets and mitigate resource constraints and improve data quality on the job training and supportive supervision. Further laboratory investigations should be done to investigate the effect of ivermectin on the parasites under laboratory conditions.

Public health surveillance (PHS) is the continuing organized gathering, investigation, elucidation, and well-timed distribution of health-related information for activities and program evaluation. Sustain the decrease of the trouble of immediately reportable diseases (IRDs), eradicate the disease, and prevent its restitution is the main aim (3).
According to Ethiopia, malaria elimination strategy, mortality, and morbidity attributed to malaria declined significantly during the review period. Accordingly, death due to malaria has declined by 67% from 0.9/100,000 population to 0.3/100,000 population at risk between 2016 and 2019. Similarly, the annual parasite incidence (API) has declined by 37% from the 19/1000 population to 12/1000 population between 2016 and 2019. The number of confirmed malaria cases has reduced by 47% between 2016 and 2019 (4).
PHS of infectious diseases is recognized as the keystone of Public Health (PH) decision-making and practice. PHS data are crucial for monitoring the health status of the population, detecting diseases, and triggering actions to prevent further illness and ensure that these diseases are monitored efficiently and effectively (5).
WHO recommends mass drug administration (MDA) of ivermectin as a potential tool to reduce malaria transmission to reach malaria vectors that feed on the temporal and spatial gaps left by core vector control interventions (long-lasting insecticidal nets and indoor residual spraying (6).
Information distributed by a PHS system can be used for immediate PH action, program planning and evaluation, and formulating research suggestions. The PHS system has been 2 | P a g e developed to address a range of PH needs. They include a variety of data sources essential to PH action (7) Malaria PHS predicts the maintenance of continuing watch over the status of malaria in a community. The main purpose of PHS is to detect changes in trends or distribution of malaria and other vector-borne diseases to initiate investigation or control measures. The aim of malaria PHS in the prevention and control of malaria in the community (8).
Conducting PHS is key for monitoring the efficacy and effectiveness of interventional programs in the health care system. Effective PHS systems are one of the basic strategies of national disease prevention and control programs. A PHS scheme serves 2 relevant roles; (i) untimely caution of likely threats to PH and (ii) program monitoring of the PHE, which could be emerging-definite or multiple-emergency in life (9). Therefore, the purpose of this study was to evaluate Trends of Malaria in the hotspot and Ivermectin mass-drug administration Zone of Amhara Regional State, Ethiopia, 2020.

Study Design and Period
The institution-based prevalence study design was used based on an "overview of evaluating PHS systems CDCs updated in the 2012 guideline for evaluating PHS system" as a framework for the evaluation to achieve the stated objective of the study from June 2020 to August 2020.

Study unit
The study units were woreda HOs and health facilities (HF). 25 study sources were included in the survey, including woreda HOs= 5, HCs= 10, and HPs= 10.

Sample size and techniques
A Zone is one of the Zone in the Amhara Region that reported an uppermost figure of cases in the region during the study. We purposely selected to conduct the PHS system evaluation in this zone. 25 sites were selected for the study. About 5(50%) woredas are selected by a convenient sampling method based on their malaria weekly report caseload and surveillance performances.
For each selected Woredas, in each selected HO: 10 HC and each selected HC: 10 HP was selected by purposive.

Selection of health facilities
HFs were selected by discussing with district PHEM officers, two HCs and two HP from each woreda were included in the evaluation, similarly, HC was included based on the 2019/2020 PHEM performance by taking HCs that had better performance and least performance. HPs were selected by purposive.

Data collection and Data source
Data collection would be done by face to face interviews using questionnaires/checklists. Answers from respondents (HO head and/or PHEM officers) and observation of tools for surveillance and secondary data review. And the increasing or decreasing rate before and after ivermectin mass drug administration was measured by the annual parasitic incidence rate. And the population data used to determine the annual parasitic incidence rate and disease rate.

Data Management and Analysis
The data were coded and entered using Epi info 7 and exported to the Statistical Package for the Social Sciences (SPSS) version 20. Then the mean prevalence, variability, and linear regression were executed by using SPSS statistical software version 20. The variances between groups were handled by analysis of variance (ANOVA). Results are presented with text descriptions, graphs, and tables.

Data Quality assurance
Data was reviewed by PH experts who have worked in the PHS system. Some data was deduplicated, especially the data from malaria monitoring charts, weekly PHEM reports, and year reports. We cleaned and analyzed data using Microsoft Office Excel 2016 and Epi-data to show report completeness, timeliness, and trends over time and the geographical distributions.
The overall report completeness and timeliness rate was above the World Health Organization minimum goals (80%) in the last five years (Fig. 1). This might be due to increasing a of the community and acceptance of the community, health extension workers, and other health providers on of the PHS.
In this analysis, we were done
The overall report completeness and timeliness rate was above the World Health Organization minimum goals (80%) in the last five years (Fig. 1). This might be due to increasing a of the community and acceptance of the community, health extension workers, and other health we were done a malaria incidence rate of the zone and woreda according to the  96.2%, 98.9%) and the average report timeliness was 96 % (95% CI: 95.5%, 97.7%) (Fig. 1).

Governmental Health Facility Awi Zone, Amhara
The overall report completeness and timeliness rate was above the World Health Organization minimum goals (80%) in the last five years (Fig. 1). This might be due to increasing awareness of the community and acceptance of the community, health extension workers, and other health

Malaria Average Annual Parasitic incidence
In the current study, the Awi zone is our study area because the second hotspot area and all woreda were Ivermectin mass drug administration targeted woreda from the Year 2015-2019 and malaria incidence rate (Table 1 and Fig. 3).

Annual parasitic incidence (API) rate
The main indicator of the effect of Ivermectin on malaria elimination here in the Figure below indicates that the current API rate. The woreda with its malaria incidence rate reported from 2015-2019 was present in Figure 4. The current finding indicates that Ivermectin did not affect the parasitic incidence rate reduction. It implies that Ivermectin was not effective in malaria elimination in Awi Zone, Amhara Regional, 2020.

Population under PHS
PHEM targets all the population to be under surveillance for all the 21 diseases nationally and 22 diseases (include Lehimaniasis) in the Amhara region. A population under PHS includes all residents selected Woreda of Awi Zone and Visited Woredas by 2020 ( Table 2). The national PHEM targets all the population in the country to be under PHS for all the 22 priority diseases. The Awi zone cascade the same structure, with a total population of 1,253,909 in 2020 with population conversion factor Region cascade from this 474012 population under PHS (Table 3). were 1(0.02%) deaths due to malaria and pregnant mother were 596 (1.5%) (Fig. 5). During the same year, Awi Zone also reported 259,009 (35.6% of the region) total malaria cases examined by RDT or Microscopy, of which 18,726 (58%) from the zone are confirmed (Fig. 6).  A Zone reported 43131 confirmed malaria cases were reported from July 2019 to August 2020.
A total of 41959 and 8793 confirmed malaria cases were reported from the woredas Ankesha, Banja, Changi, Guasgusa, and Zigem respectively to Awi Zone from July 2019 to January 2020.

DISCUSSION
This study intended to the purpose of the evaluation of the trend of malaria in Awi zone, Amhara Region, Ethiopia, 2020 by seeing the effect of ivermectin on malaria reduction and by describing and measuring the core activity and supportive function of the surveillance system and surveillance attributes in the district, overall performance and using indicators to identify gaps or areas that could be strengthened.
We However, in some woredas, the distribution of Plasmodium vivax species is higher than that of the spreading of falciparum which is not matched to the national guideline standards. These woredas include Guagusa Shekudad and Zigem. Some studies also supported these findings, which dedicated an increased proportion of Vivax malaria is consistent with a study at high altitude in the Butajira area (24), the decrease in Vivax malaria in highland-fringe areas could be explained by the high transmissibility of P.vivax. The P. falciparum prevalence increased by 75% in 2015 to 86% in 201/2015, this was higher than the national report 2019 (4,11).
This study provided that the following woredas, for example, Ankesha Guagusa, Banja, Guagusa Shikudad, Changi, and Zigem had the mean yearly anticipated occurrence of definite malaria higher than twenty per thousand human, this may be due to the higher number of reporting sites, arid areas and the presence of agricultural programs could affecting diseases spread where incidence be higher than expected and the rest of woreda be constantly under 5 reported malaria per thousand population per year (4,12). In general, the utilize of prevalence while contrasting between woreda get better the capability of the zone to map property properly, develop targeted diseases organize labor, and permit an improved assessment of the program.
Supportive supervision helps to strengthen the capacity of staff and make sure that the proper skills are used appropriately; the mandatory logistics are in place, which planned activities are implemented in keeping with the schedule. Supervision is a vital support function that ensures success within the implementation of a surveillance system. A well-functioning system is often insured by regular and purposeful supervisory support. Within the woreda we visited during data collection, there have been not doing regular feedback and supportive supervision given to the lower levels. Supportive supervision was done just one time during the year 2019/20 which was but the expected plan (12).
Epidemic preparedness refers to the prevailing level of preparedness for potential epidemics and includes the availability of preparedness plans, storing, a designation of isolation facilities, setting aside of resources for outbreak response, at the least bit levels; There have been no wellorganized epidemic preparedness and response planning, and no financial and/ or support. This could cause weak case detection and response during epidemics.
Preparedness aims to strengthen capacity in recognizing and responding to public health emergencies through conducting regular risk identification and analysis, establishing partnerships and relationships, improving community participation, and implementing community-based interventions and strategic communication during the pre-emergency phase and ensuring their monitoring and evaluation (13).
The ability of the system to capture true diseases regarding malaria was assessed in this evaluation. On this basis, the predictive value positive for malaria by case definition was low in malarious districts of the Awi zone as the majority of them were greater than 35% for the year 2019/20. This was greater than the guideline developed by the Minister of Health of Ethiopia (4,12).
The wholeness of coverage of malaria pointers for the PHEM scheme in the Awi zone within 2015 to 2019, and accomplished that more than 96% had adequate excellence to produce measures of malaria occurrence by reporting woredas (14 ), Which is above the 80% WHO target (13,14), viewing that everyone visited HFs were reporting to their respective level as per the quality within the country principle.

5: CONCLUSIONS
The current PHS study revealed that the malaria incidence rate showed a remarkable decline.
However, the annual parasitic incidence rate remains constant. This indicates that ivermectin did not affect malaria elimination.
Health care providers and health extension workers have a good understanding of the case definitions of malaria, other priority diseases, and surveillance. Report completeness and timeliness were good which above the national target both for the woreda and HFs. Laboratory diagnosis of malaria was available at all levels of the district and HFs were satisfactory. They only prepared a plan, there is no ready budget and resources to respond to any PHEM. Data analysis is only done at the zonal level, there was a lack of skill and resources for data analysis at the district and facility level. Outbreak investigation and response activities were done in a good manner. Supervision activities were poor at the zonal and district level, there were no program-specific supervision activities other than integrated supportive supervision which were conducted in each quarter. This could be due to the bad direction of all parties, insufficient helpful supervision and feedback, little or no law enforcement to the PHS activities, lack of incentives, appropriate training, sense of ownership, and logistics.
The finding suggests the importance of PHS training for focal persons and strict follow-up of the implementation of the acceptable surveillance system might improve PHEM capacity.
Besides, minimizing the irrational case definition of diseases could also help to improve PHEM capacity.

Declarations
Ethics approval and consent to participate: Ethical clearance was obtained from the Institutional Review Board of the Jimma University and an official letter was submitted to the concerned bodies. The concerned bodies were informed to get the assurance of the study and confidentiality was maintained at all levels of the study. Informed consent was obtained from all participants and the Institutional Review Board of the Jimma University approved it with Ethical approval of Research protocol letter with its reference number IRB00010/2020.

Informed consent
Dear Sir/madam; My name is __________and I am from__________. I am conducting data collection on the Trends of Malaria on Hotspot and Ivermectin Mass-drug Administration Zone of Amhara Regional State, 2020. The study being conducted by Mr. Chalachew Yenew from Jimma University.
You are kindly requested to be included in the study, which has great importance in improving health. The interview will take a maximum of __________minutes.
No information concerning you as an individual will be passed to another individual or institution. Your participation will be based on your willingness and you have the right not to participate fully or partially. If you agree to be included in the study, I will start my question by asking general identification questions.
1. Agree to participate__________ 2. Do not Agree to participate_______

Consent to Publish: Not applicable
Availability of data and materials: All data generated and analyzed during this study are included in this manuscript itself.
Competing interests: The authors have announced that they have no competing interests in nonfinancial includes political, personal, religious, ideological, academic, and intellectual and Financial issues.

Funding: Not Applicable
Authors' contribution SM is actively involved during the conception of research issues and development of research proposals and CY has been writing of various parts of the research report and prepares the final manuscript. All authors read and approved the final manuscript.