Malaria control program managers mainly depend on case reports from health facilities to make major intervention decisions . The fact that decisions are made mainly based on case reports puts the entire program on passive posture, i.e. if other outbreak alert and response methods such as entomological information, weather forecast, regular cross sectional malaria indicator surveys are not in place, the program office will always left with to play catch-up to contain the disease outbreak (Maharaj 2017). While case reports from health facilities always remain a critical component in deriving both policy and strategic decisions, they may not sufficiently provide the necessary information regarding malaria transmission intensity, hot spots, and endemicity problem. In this study, key malaria disease control indicators were assessed in Jabi Tehnan district using household level KAP and cross-sectional malaria parasitological surveys. In addition, recent trend of malaria cases and its implication for malaria elimination was evaluated.
The socio-demographic features of community members in the study area were similar to those reported from other parts of Ethiopia including a pre-dominance of male-led households, high level of illiteracy and engagement in agriculture as the main community occupation . The average family size of 5.6. reported here is slightly higher than the country average of 4.6 . It might be economically difficult for large households to buy enough insecticide-treated bed nets and this is documented in studies conducted in Gambella and Jimma, Southwestern Ethiopia [32, 33]. Most members of the community have separate cattle sheds or houses, and this is an important behavioral difference documented compared to the reluctance of families in most parts of Ethiopia to separate cattle from human residences. Keeping livestock away from human residences is acknowledged as a practical strategy for diverting certain malaria vector species from human hosts to other vertebrate hosts, thereby, decreasing the contact between humans and infectious mosquitoes [34, 35]. Houses in this study were made of walls with wooden frames, plastered mud walls and roofs made of corrugated iron sheets. The absence of traditional huts with grass thatched roofs could be partly explained by improved economic status of the community . The coverage of households in the area with LLINs was found to be moderate, with every household having at least 0.5 LLINs and with total coverage being 70%. This was below the country and regional average of 72% and 76% respectively .
Both Long-lasting Insecticidal Nets (LLINs) and Indoor Residual Spraying (Propoxur, 1-2g.m2) were being used in the district with IRS given priority to 4 villages (Ergib, Awunt, Hodansh and Jiga Yelimdar) which had higher ongoing transmission. LLINs was the only intervention available throughout all the health clusters of the district. Universal coverage (100% access) was ensured in the district as confirmed through FGD, personal observation and information obtained from the district health department. Supplementary interventions such as filling and draining of standing water were reported by FGD participants even though they were not regularly implemented. Major emphasis was given to case treatment and bed net distribution from malaria control program office of the district.
Universal coverage or access to at least one vector control intervention/per household is the direction adopted by national malaria control program since 2006 in Ethiopia . Low utilization of the already available interventions and using nets for unintended purposes however remains major challenges in the area as close to half (50%) of the households who had access to bed nets did not use it in the previous nights in the area. Lack of persistency in using bed nets is a cross-cutting problem throughout the country as it is assessed in country wide malaria indicator surveys . Continued community education and communication effort should be done in order to bring the desired behavioral changes.
As it is confirmed in this study there is high prevalence of misuse of bed nets. Thus, there is serious gap in behavioral change to be addressed from all stakeholders involved in malaria control programs. Studies documenting misuse of bed nets in Ethiopia are not many, but a study conducted in Adame-Tullu district of East Shewa zone, central Ethiopia showed that misuse of bed nets for other purposes such as wrapping maize kernels, wrapping teff and transporting it from field to home using animal carts are the common acts of misuse .
In this study we assessed different traditional practices including vector control and diseases treatment approaches used by the communities in the study area. Despite the reliance on modern medicine predominantly as the participants described, some community members believed that extracts from leaf and succulent parts of different plants such as Ocimun lamiifolium (loc. “damakese”), Phytolacca dodecandra (“Indod”), Clausena anisate (“limmich”), Croton macrostachyus (“Bisanna”) and mashed garlic could be used for treating malaria. Provision of traditional medicine for malaria remedy is a long-established trend in Ethiopia [38, 39]. While the essence of indigenous knowledge is undoubtedly important in the quest of new anti-biotic options, the anti-malarial potential for the plants has not scientifically established yet.
The delayed treatment-seeking behavior observed in this survey is also a common problem documented throughout the country with reports from Central , South East , Western  and Southwestern Ethiopia . While the cessation of death due to malaria in Jabi Tehnan district is an achievement, the disease continues to cost considerable working days (2.53 per person-per episode) due to morbidity and money spent on treatment (18.18USD/person/episode). The economic impact of malaria is analyzed from different perspectives including the death of workers, school absenteeism, loss of family members’ time due to caring, loss of savings, loss of household and farm assets . The reported working days lost due to malaria is relatively low as compared to recent studies conducted on malaria economic impact in Ethiopia which estimates loss of 6.3 working days, but money spent per episode per person was relatively high as compared to the 17.8USD expense/episode/person  in Ethiopia and Kenya with loss of 5 USD .
Health posts and government hospitals were reported to be the main source of treatment in the area. Malaria treatment is freely accessible in Ethiopia through government health institutions (Health Posts, Health centers, and hospitals) . Despite free access to malaria treatment at every village level in the district and in other parts of the country, some people either did not seek treatment at all (7.66%) or used other unreliable treatment sources such as traditional healers (1.6%). This showed that there are still significant gaps in the awareness level of the community in treatment-seeking behavior.
Malaria disease prevalence in Jabi Tehnan district was low (0.89%). In this survey Plasmodium vivax was the main parasite documented in the area followed by Plasmodium falciparum. Besides, all positive samples were documented in areas well below 2000 metres above sea level, between 1300 and 18000 metres. As Jabi Tehnan is one of the 239 districts selected for malaria elimination in the country , the current low prevalence rate gives hope for the envisaged elimination program However, the recent resurgence in some of the villages (Ergib, Goref, Abasem, Jiga Yelimdar, and Guay) may jeopardize the plan.
Malaria case reports from health facilities in the area were collected concomitantly to make comparisons and cross-validations with prevalence data. Accordingly, those villages where positive cases were found in the cross-sectional survey had also the highest share of cases as reflected in clinic-based data in the district. Jiga and Awunt had reported considerably higher cases with the former being the second and the latter being fourth most affected in the district. However, no positive case was found in the cross-sectional parasite survey. Moreover, malaria disproportionately affected the adult segment of the population as 50% of the total case was reporteded from people whose age was 15 and above followed by the age between 5 and 14. In Ethiopia, malaria transmission is unstable and highly seasonal with few exceptions of areas bordering Sudan and South Sudan. This has resulted in low host immunity and risk of the adult population being more affected unlike the trends observed in other parts of Africa [1, 48].
Overall malaria cases have been substantially declined in the last five years in Jabi Tehnan district. Thus, the highest malaria case was documented in 2016 and the least case was documented in 2019. There was 80% reduction of cases in the last five years, however, comparison of the last two years data (2018 and 2019) showed that case reduction had almost flattened. This is a common problem across Africa as a certain portion of malaria vectors defy the existing vector control efforts . It becomes clear that even with universal coverage of mainstay vector control interventions, there will be still sustained transmission due to outdoor transmission .