Malaria epidemiology and stratification of incidence in the malaria elimination setting in Harari Region, Eastern Ethiopia

Background: Ethiopia has shown notable progress in reducing the burden of malaria over the past two decades. Because of this progress, the country has shifted efforts from control to elimination of malaria. This study was conducted to analyse the malaria epidemiology and stratification of incidence in the malaria elimination setting in eastern Ethiopia. Methods: A retrospective study was conducted to analyse the epidemiology of malaria by reviewing the district health office data from 2013 to 2019 in Harari Region. In addition, three years of sub-district level malaria data were used to stratify the malaria transmission intensity. Malaria interventions (Long-lasting insecticidal nets [LLIN] and indoor residual spraying [IRS]) employed were reviewed to analyse the intervention coverage at the Regional level. Descriptive statistics were used to show the malaria transmission in terms of years, season and species of the malaria parasite. Incidence rate per 1000 population and death rate per 1 000 000 population at risk were computed using the total population of each year. Results: In the Harari Region, malaria incidence showed a more pronounced declining trend from 2017 to 2019. Plasmodium falciparum, P. vivax and mixed infections accounted for 69.2%, 30.6% and 0.2% of the cases, respectively. There was an increment in malaria intervention coverage and improved malaria diagnosis. In the year 2019 the coverage of LLIN and IRS in the Region were 93.4% and 85.1% respectively. The annual malaria incidence rate dropped from 42.9 cases per 1000 population in 2013 to 6.7 cases per 1000 population in 2019. Malaria-related deaths decreased from 4.7 deaths per 1 000 000 people annually in 2013 to zero, and there have been no deaths reported since 2015. The malaria risk appears to be heterogeneous and varies between districts. A higher number of malaria cases were recorded in Erer and Jenella districts, which constitute 62% of the cases in the Region. According to the sub-district level malaria stratification, there was shrinkage in the malaria transmission map and about 70% of the sub-districts have achieved elimination targets. Conclusions: In the Harari Region, malaria morbidity and mortality have been significantly declined. Thus, if this achievement is sustained and scaling-up of the existing malaria prevention and control strategies by focusing on those populations living in the higher malaria transmission districts and sub-districts, planning of malaria elimination from the study area might be feasible.