Prevalence of Malaria and Its Associated Factors Among Malaria Suspected Patients Attending at Hamusite Health Center, Northwest Ethiopia, a Cross Sectional Study, 2020

Background Malaria is a major public health problem which still results in illness and death. Despite efforts to reduce the mortality and morbidity of malaria, the disease is still a prominent health problem in Ethiopia. This study, therefore, was undertaken to assess the prevalence of malaria and associated factors among symptomatic patients in northwest Ethiopia. Method A facility based cross-sectional study was conducted from February to March 2020 among 210 febrile patients attending at Hamusite health center, northwest Ethiopia. Thin and thick blood lms were prepared from blood collected by nger puncture and from capillary blood buffy coat. Data were analyzed using SPSS version 20.

Humans are primarily infected through the bite of an infected female Anopheles mosquito that inoculates sporozoites during blood meal [11]. Anopheles arabiansis, a species responsible for malaria epidemics, is the primary vector in Ethiopia leaving the country at risk of repeated outbreaks [1]. After inoculation, parasites circulate with blood and those reaching to the liver undergo one cycle development. Then after, parasites infect and multiply inside red blood cells to bring the characteristic sign and symptoms [12]. The clinical manifestations include fever, headache and vomiting which usually appears between 10 and 15 days after the mosquito bite. If not treated, it can become life-threatening by disrupting the blood supply to vital organs [13] which results complications including anemia, impaired consciousness, respiratory distress, hypoglycemia, jaundice and nally it may cause death [14]. Despite efforts to reduce the mortality and morbidity of malaria in endemic areas by utilization of insecticide treated nets (ITNs), environmental control, chemoprophylaxis, and rapid case detection followed by prompt case management [15], the disease incidence shows little decline in the country. Hamusite, located in northwest Ethiopia, is among the top malaria affected areas in Amhara Region. An updated data in such high risk areas helps for timely and targeted intervention. Therefore, this study was undertaken to assess the prevalence of malaria and associated factors among malaria suspected patients attending at Hamusite health center.

Methods Study Design, Area and Period
A facility based cross-sectional study was conducted at Hamusite Health center, northwest Ethiopia from February to March 2020. Hamusite town is administratively part of Dera district and it is located at geographic coordinates of 11° 43' 0'' North and 37° 38' 0'' East. The climate of the area is woyna dega and has an average annual rain fall of 1300 mm and mean annual temperature of 26°C (source: Woreda o ce of agriculture). The health center serves for 55, 422 people in the catchment area. Owing to low altitude and irrigation activities, malaria is a common public health problem in the area.

Sample size Determination and Sampling Technique
Sample Size and Sampling Technique The sample size was calculated using single population proportion formula based on the 95% con dence limits (Zα/2 = 1.96) and 4% margin of error (d) and previous prevalence (p) of 8.7% in from previous study conducted in Aysaita primary hospital, Northeast Ethiopia [16].
Sample size = (Zα/2) 2 p (1-p)/d 2 = (1.96) 2 (0.087) (1-0.087)/ (0.04) 2 = 191 After compensating for non-responsedents, 19 (10%), the nal sample size was 210. Patients who visited the health center laboratory for blood lm examination and met the eligibility criteria were recruited by systematic random sampling technique considering the case ow in the health center from February to March of the previous year. Febrile patients clinically suspected of malaria who were 5 years-old or above and willing to participate in the study were included. Individuals who took anti-malarial and antibiotics therapy with in the past one month before enrollment were excluded.

Malaria Risk Factor Assessment
A structured and pre-tested questionnaire was adapted from the 'National Malaria Indicator Survey Household Questionnaire'. It was administered to gather information on socio-demographic variables that included sex, age, family size, residence, marital status, level of education, occupation, clinical data of study participants.
Data about malaria control activities including indoor residual spraying (IRS) in the past 12 months, number of ITNs owned per house hold, presence of hole in the wall, presence of surface water with in 500m from home, type of surface water, distance of surface water from home, habit of sleeping or working outside at night were also collected.

Blood Sample Collection and Processing
Capillary blood was obtained via nger puncture. In order to collect capillary blood, the patient's nger was cleaned with 70% ethyl alcohol and the side of ngertip was pricked with a sterile lancet. The rst drop of blood was wiped away and approximately 2µl and 6µl of blood were placed on a glass slide to prepare thin and thick blood lms, respectively. Furthermore, buffy coat was prepared from capillary blood samples using heparinized capillary tube. The Capillary tube containing blood was centrifuged at 1200 revolution per minute for 5 minutes and the buffy coat and the red cell layer just below the plasma (approximately 1-2 mm) was aspirated using a micropipette and used for thin and thick lm preparations. Thin and thick blood lms were simultaneously prepared from each participant and stained with 10% Giemsa for 10 minutes and then examined microscopically following standard protocol for detection and identi cation of plasmodium species. Asexual parasite stages and gametocytes were counted separately from each positive smear against 500 and 1000 WBCs, respectively [17].

Data Processing and Analysis
Data were coded, entered, cleaned and then analyzed using Statistical Package for Social Science Software version 20. Descriptive statistics like frequency, percentage and mean were manipulated to explain the study participants and to show the malaria prevalence and parasite load. Binary logistic regression and multivariate analysis were run to assess the association between socio-demographic and other independent variables with malaria infection. Odds ratio (OR) with the corresponding 95% con dence interval (CI) was used to determine the strength between dependent and independent variables. Associations were considered as signi cant only if P-value was less than 0.05.

Clinical Data of Study Participants
Out of 210 study participants, 177 (84.3%) had axillary temperature of 37.5 0 C and above where as 96 (45.7%) and 114 (54.3%) had malaria history with in the previous 1 year and had family members with history of malaria, respectively. Two hundred three (96.7%) participants were with fever while 179 (85.2%) and 191(91%) patients complained for headache and nausea, respectively ( Table 2).

Malaria Control Activities and Conditions
Insecticide treated bed net and draining stagnant water were the most commonly mentioned malaria prevention measures reported by 71.9% and 8.1% of the respondents, respectively. Forty one (27.1%) patients responded that their households owned two ITNs. Nearly one-third (31.5%) of the participants responded that their homes were sprayed with IRS within a year before data collection ( Table 3).

Prevalence of Plasmodium Species
Overall, 61 (29.0%) participants were con rmed to be infected by Plasmodium species. Plasmodium distribution at species level revealed that P. falciparum mono-infection accounted for the highest frequency, detected in 41 (19.5%) participants. Asexual parasite stages were detected in 59 participants while only gametocytes were detected in 2 patients (Table 4).

Factors Associated with Plasmodium infection
The prevalence of malaria regarding to sex of the participants was 21.9% in males and 36.2% in females.
Females were 2.261 times more likely to be infected with malaria than males (AOR=2.261; 95%CI=1.118-4.571). In addition, individuals who had family members with history of malaria were about 2.598 times more likely to be infected with malaria than those having family members with no history of malaria (AOR=2.598; 95%CI=1. 26-5.340). The distribution of malaria was higher among rural residents (29.5%) than that of urban residents (23.5%); however the difference was not statistically signi cant (Table 5).

Discussion
Malaria is a major health burden widespread throughout tropical and subtropical regions of the world including Ethiopia. In the present study, the overall prevalence of malaria infection (29.0%) was lower than previous study ndings ranging from 33.8% to 53.68% in Ethiopia [18][19][20][21].The present results were also lower than prevalence of 64.5%, 32.4% and 41.6% from Tanzania [22], Liza [23], and Nigeria [24], respectively. The low prevalence in the present study might be due to difference in the study period (since our study was conducted in minor transmission season from February to March), variation in implementation of malaria control and prevention activities and variation in local epidemiology of malaria parasites. However, the present prevalence was higher than similar study results conducted in different geographical settings of Ethiopia where the prevalence ranged from 4.7% to 25.8% [25 -31]. It was also higher than 27.6% prevalence report from India [32]. Malaria parasitemia in this study was also higher as compared to similar study results from Bangladesh (0.76%, 3/400) [19]; India (0.08 %, 14/17209) [31] and north Ethiopia (1%, 6/600) [27]. The high prevalence in the present study might be due to application of buffy coat examination in the present study, which is more sensitive technique than conventional blood lm examinations. Moreover, variation in the transmission of the disease across geographical settings also matters.
Majority of the infections (19.5%, 41/210) in the present study were caused by P. falciparum while each of P. vivax and mixed infections contributed for 4.8% (10/210) of the infections. This was in agreement with previous study nding conducted in Arsi Negele where the prevalence of P. falciparum, P. vivax and mixed infections were 19.8%, 7.4% and 6.2%, respectively [32].The present species level distribution is in line with the national species distribution in Ethiopia where P. falciparum accounts more than 60% of the infections while P. vivax is responsible for approximately 40% of the infections [33].
According to the present study, individuals who had family history of malaria were 2.598 times more likely to be infected by Plasmodium species as compared to their counterparts (p = 0.009). This might be due to the fact that family members with history of malaria infection may become reservoirs for Plasmodium parasites and serve as sources of infection for the rest of the family members. In addition, the present data showed that females were 2.261 times more likely to get infected as compared to males (p = 0.023). On the contrary, a study conducted at Kola Diba Health center reported that males were more affected than females [34].
Variations in nature of occupation and outdoor sleeping habit among males and females might bring such differences. All the other considered factors (Table 5) were not signi cantly associated with Plasmodium parasitemia. However, it is di cult to justify why those factors were not associated because we have recruited small number of participants. Moreover, we collected at health institution which was not supplemented with observation to increase the data quality like how they are using ITN.

Conclusions
The prevalence of malaria among febrile patients attending Hamusite Health center is signi cantly considerable. Moreover, P.falciparum was identi ed as the most pathogenic species responsible for the majority of the infections in the area. Individuals with female sex and those having family history of malaria infection were at higher risk of Plasmodium infection. Therefore, efforts must be made to expand and sustain the combined application of ITNs, IRS and larval source management at Hamusite town and the rural localities. In addition, encouraging family members infected with plasmodium species to seek timely treatment is also important to minimize the risk of infection among other family members. Review Committee with project code of 008/2020 prior to the commencement of the study. Permission letter was obtained from APHI and Support letter was also obtained from South Gonder Zonal Department, Dera Wereda Health O ce and Hamusite Health Center. Informed consent and assent (for <18 years-old participants) was obtained from each study participant. Study participants with positive result for any malaria parasite were linked to the health center for appropriate treatment.

Consent for Publication
Not applicable

Availability of Data and Materials
The original data for this study is available from the corresponding author

Competing interests
The authors declare that they have no competing interests Funding Samara University was give fund for execution of the study Authors' contributions Getu A: undertook the data collection and participated in statistical analysis and manuscript preparation.
Woyneshet G: participated in data analysis and write up of the manuscript. Getaneh A: conceived the study, participated in data analysis and write up of the manuscript. All authors read and approved the nal version of the manuscript.

Acknowledgments
We are grateful to ethical review board of Bahir Dar University for giving ethical clearance. Our regards also go to the study participants for participating in the study. We also thank APHI, South Gonder Zonal Health Department, Dera Woreda Health O ce, and Hamusite Health center for giving permission to perform data collection.