Five-year Surveillance of Malaria in Hotspot and Ivermectin Mass-drug Administration Zone of Amhara Regional State, Ethiopia

Objectives: Evaluate the ve-year surveillance of malaria in the hotspot and Ivermectin mass-drug administration Zone of Amhara Regional State, Ethiopia. Methods: - A descriptive prevalence study design was employed and incorporated 25 study health institutions into the survey using the purposive sampling technique. Data were obtained by the standard format of systematic evaluation of four surveillance units from January to August 2020 through observation, document review, and interviewing surveillance ocers and focal persons using a semi-structured Survey and generated the statistical analysis, tabular, and graphical output using the open-source statistical program R. Results: - Average report fullness and aptness were 97.9% and 96% subsequently. The average annual malaria incidence rate declined in terms of place and time, from the year 2015 to 2019 with an average reduction rate of 5.5% and the average annual parasitic incidence rate was 52%. The study identies high endemicity of malaria due to no program-specic supportive supervision of public health emergency management and no routine data analysis. Conclusions: This result revealed that the malaria incidence rate showed a remarkable decline. However, the annual parasitic incidence rate remains constant. The study also indicated that ivermectin did not affect malaria elimination. Hence, the districts and sub-city health oces should conduct regular surveillance data analysis, perform supportive supervision, avail budgets, and further laboratory investigations to investigate the effect of ivermectin on the parasites under laboratory conditions.


Background
Intestinal parasitic diseases like malaria are curable. But, life-threatening infections cause intense febrile sickness, which taints the human liver and red blood cells. It is transmitted from individual to individual by the chomp of the Anopheles mosquito, which chomps as it were at night. It is transferred to individuals via the chomps of Anopheles mosquitoes, called malaria vectors, taints with Plasmodium parasites (PPs) (World malaria report, 2019).
In 2018, assessed 228 million diseases of malaria occurred globally (95% con dence interval (CI): 206-258 million), in contrast with 251 million infectious in 2010 (95% con dence interval (CI): 231-278 million) and 231 million infections in 2017 (95% con dence interval (CI): 211-259 million). In the 2018 World Health Organization (WHO) malaria report showed that the African Region (213 million or 93%), followed by the South-East Asia Region with 3.4% of the diseases and the Eastern Mediterranean Region with 2.1% and In 2018, there were an estimated 405 000 mortality from malaria globally, compared with 416 000 determining mortality in 2017, and 585 000 in 2010 (The Carter Center, 2012).
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 decreased trouble of immediately reportable diseases (IRDs), eradicate the disease, and prevent its restitution are the goals (World Health Organization, 2018).
According to Ethiopia, malaria elimination strategy, mortality, and morbidity attributed to malaria declined signi cantly during the review period. Accordingly, death due to malaria 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 the 12/1000 population between 2016 and 2019. The number of con rmed malaria cases has reduced by 47% between 2016 and 201 (Chala, 2020).
PHS of infectious diseases are recognized as the keystone of Public Health (PH) decision-making and practice. The data of PHS for monitoring the health status of the population, detecting diseases, and triggering actions are crucial (World Health Organization, 2018).
WHO recommended 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 (Chaccour et al., 2017).
Information distributed by a PHS system used for immediate PH action, program planning and evaluation, and formulating research suggestions. PHS system developed to address a range of PH needs. They include a variety of data sources essential to PH action (German et al., 2001).
Malaria PHS predicts the maintenance of continuing watch over the status of malaria in a community.
The primary purpose of PHS is to detect changes in trends or distribution of malaria and other vectorborne diseases to initiate investigation or control measures. Aims of malaria PHS is the prevention and control of malaria in the community (World Health Organization, 2013).
Conducting PHS is a clue for monitoring the e cacy 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 two relevant roles; (i) untimely caution of likely threats to PH and (ii) program monitoring of the PHE, which could be emerging-de nite or multiple-emergency in life (Anam et al., 2019). Therefore, the purpose of this study was to evaluate Five-year surveillance 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 employed based on an "overview of evaluating PHS systems CDCs updated in the 2020 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 technique
Awi zone is one of the zones in the Amhara Region that reported an uppermost gure of cases in the region during the study. We purposely selected to conduct the PHS system evaluation in this zone based on previous malaria hotspot and Ivermectin mass drug administration. A 25 health institutions (05 HO: 10 HC and each selected HC: 10 HP) included in the study using a purposive sampling method based on their malaria weekly report caseload and surveillance performances.

Data collection and sources
Data collection was done by face-to-face interviews using questionnaires/checklists. HO head and PHEM o cers responded and observed the activities of 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 the disease rate.

Data management and analysis
We coded and entered the data using Epi info 7. The analysis and statistical tabular and graphical output generated using the open-source statistical program R. The results were presented with text descriptions, graphs, and tables.

Data Quality assurance
We reviewed the data by PH experts who have worked in the PHS system. Some data was de-duplicated, especially the data from malaria monitoring charts, weekly PHEM reports, and year reports. We cleaned and analyzed data using Microsoft O ce Excel 2016 and Epi-data to show report completeness, timeliness, and trends over time and the geographical distributions.

Results
According to the open-source statistical program R output, the average completeness of the weekly report collected from 2015-2019 was 97.9% (95% CI: 96.2%, 98.9%). The average report timeliness was 96 % (95% CI: 95.5%, 97.7%) (Fig. 1). The overall report completeness and timeliness rate was above the World Health Organization minimum goals (80%) in the last ve years (Fig. 1). The difference might be due to increasing awareness of the community and acceptance of the community, health extension workers, and other health providers of the PHS.
In this analysis, we were done a malaria incidence rate of the zone and woreda according to the previous 5-year data to identify the hotspot zone and woreda. The surveillance data from the year 2015-2019 provided that North Gondar (59.7), Awi (54.3), South Gondar (27.5), and West Gojam (26.3) per 1000 populations had the highest Annual average incidence rate (Fig. 2). 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). (1.5%). 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 con rmed (Fig. 5).

Discussion
This study intended to evaluate the ve-year surveillance of malaria in Awi zone, Amhara Region, Ethiopia, 2020 with the effect of ivermectin on malaria reduction by describing and measuring indicators. However, in some woredas, the distribution of Plasmodium vivax species is higher than that of the spreading of falciparum which not matched the national guideline standards. These woredas include Guagusa Shekudad and Zigem. It is agreed with the study conducted at the Butajira area, which dedicated an increased proportion of Vivax malaria at high altitudes, the decrease in Vivax malaria in the highland-fringe area and the high transmissibility of P.vivax. The P. falciparum prevalence increased by 75% in 2015 to 86% in 201/2015, and higher than the national report 2019 (Delil et al., 2016).
This study provided that the following woredas, for example, Ankesha Guagusa, Banja, Guagusa Shikudad, Changi, and Zigem had the mean yearly anticipated occurrence of de nite 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 (Rabbani et al., 2016). 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.
There have been no well-organized epidemic preparedness and response planning, and no nancial 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 identi cation 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 (FDRE Public Health institute, 2012).

Limitation Of The Study:
Small sample size and Regional one due to resources shortage.

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.
The nding 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 de nition of diseases could also help to improve PHEM capacity. 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 identi cation questions. Availability of data and materials: All data generated and analyzed during this study are included in this manuscript itself. Figure 1 The open-source statistical program R graphical outputs of the timelines & completeness of the reports of different woreda of Awi Zone, Amhara Regional State, Ethiopia, 2020.