Much of East Africa is endemically infected with various strains of malaria. The problem is most acute in nations that have not established well-managed programs of vector eradication, or in countries with migratory, refugee or citizen displacement problems. Nations such as Somalia, Ethiopia and Eritrea, in the Horn of Africa, are particularly susceptible to this parasitic infection, which wreaks havoc with its victims’ vital organs and, over time, leads to premature death. This paper will review several of the major epidemiological characteristics of malaria and will propose some directions which Eritrea, in particular, might be well advised to pursue.

Malaria is, by all indications, a major public health problem in Eritrea. Data available from the Eritrean Ministry of Health indicate that malaria is the most common cause of death among adults and children over five and the third most common cause of death in children under five (MOH, 1995). Nearly two-thirds of the population is at high risk of infection, and cases diagnosed as malaria account for 32% of outpatient visits and 24% of hospital admissions at government health facilities. These statistics also indicate that Plasmodium falciparum is responsible for over 90% of malaria infections in Eritrea.

The geography of Eritrea includes lowlands in the west, central highlands, and coastal plains along the eastern coastal boundary. All levels, high to low risk, of malaria endemicity exist in the country. In the lowlands, malaria is generally endemic with moderate to high intensities of transmission. Here, there is a risk of epidemics in non-immune populations that migrate into the area, such as during refugee or displaced citizen resettlement programs, troop mobilization, or internal displacements such as those during the recent war with Ethiopia. Malaria in highland areas is highly seasonal and unstable, with frequent waves of epidemics. These waves of malarial infection result in high morbidity and mortality during the planting season when the rains start and during the harvesting season when the rains cease. Peak transmission occurs in two periods, September through November and January through March, with some variation among the country's six identified zones (MOH, 1995; CDC, 2000).

Since establishing a national malarial control program in 1995, the Government of Eritrea has made noteworthy progress in raising public awareness, ensuring the supply of anti-malarial drugs, building capacity for case management, and promoting the use of insecticide-treated bed netting.

The government’s program is largely decentralized; and, district coordinators exercise significant authority in determining how resources will be allocated and in selecting appropriate interventions. Occasionally, their decisions are not always the wisest.

The MOH led a government-wide effort to prepare the National Malaria Policy and Guidelines, completed in 1998, and a "Five Year Plan of Action for the Control of Malaria in the Context of Roll Back Malaria", completed in 1999 (Alemu, 1999). The stated general objective is "to reduce morbidity and mortality due to malaria to such low levels that malaria is no longer a public health problem in Eritrea" (MOH, 1999; Alemu, 1999). The Plan takes an integrated approach, combining the use of available interventions:

• individual case management;

with efforts to improve surveillance, program management, operational research, and community awareness and mobilization. The MOH is implementing its program, with assistance from international organizations including USAID, the Italian Cooperation Agency, WHO and the World Bank.

There are several elements of the NGO-MOH Joint Five-Year Plan that rely on the development of better information regarding the epidemiology of malaria. One of the Plan's "priority actions" is to "predict, prevent, detect, and contain epidemics." The Plan's "cross-cutting themes" include "building capacity for operational research" and "strengthening the information system so that future planning is evidence-based," according to published MOH brochures.

As of 1999, and into the year 2000, USAID has been, and is, also initiating a program of technical assistance to Eritrea’s malaria control program. One of the USAID's goals is to help the MOH

This program will include activities such as epidemiological surveys, developing site surveillance, improving data analysis systems, and helping malaria control officials at the central and district levels use information from surveillance and operational research activities to plan vector control efforts.

As mentioned earlier, Plasmodium falciparum and Plasmodium. vivax seem to be prevalent species in Eritrea. The WHO confirms that generic plasmodium malaria is also found but is not of epidemiological importance (2000). In the 1970's and early 1980's, P. falciparum and P. vivax were found distributed with a relative frequency of 60% and 40% respectively, according to these same reliable sources. During the last few years, however, a new trend is developing throughout Eritrea. Indeed, the frequency of P. falciparum is steadily increasing. As late as 1993, P. falciparum was responsible for 94% of the total recorded malarial infections in this nation (MOH, 1995). Such dominance of P. falciparum will have a definite impact on the incidence of severe and complicated malaria and on the development and spread of drug resistance.

Resistance, in fact, was already occurring as early as 1982 to quinine prophylaxis (Cholorquin and Camoquin) and this traditional approach can no longer be continued on a wide scale in some regions of the country (MMWR, 1982). Fansidar is being recommended now under some circumstances.

In Eritrea, more than twenty anopheline species of mosquito vectors have been recorded and Anopheles gambie sl is the primary vector with Anopheles culcifacis adenensis, Anopheles funestus and Anopheles pharoensis as secondary and tertiary vectors. Anopheles gamie sl is found in most parts of the country except in the Red Sea coast of Assab; whereas Anopheles culcifacis adenensis is found only along the Red Sea coast of Assab and its surrounding areas. Anopheles funestus and Anopheles pharoensis are found distributed in some parts of the country except in the coastal areas. (WHO, 1999; MOH, 1995)

As a whole, malaria is a threat to the country in terms of its commercial and industrial development programs. This situation is also anticipated to become much worse with the development of dams and irrigation systems for developing agriculture and with the return of 500,000 newly repatriated Eritrean refugees from Sudan. The nation’s population, living in malarial areas, constitutes some 2.4 million persons. Relatively few of those subjected to high risk of malaria live in urban areas, while the vast majority resides in rural zones heavily infected due to the absence of effective vector control programs. The Government has been improving, however, in recent years, and attention should be turned to some priorities that the MOH has identified for vector control.

As alluded to earlier, in order to protect against economic damage nationwide and to control vectors throughout Eritrea, an integrated anti-vector strategy has been generally followed. Strategies currently being employed by the MOH, in conjunction with other agencies, include:

• Environmental vector control;

The economic plight of most African nations is linked inextricably to the presence of disease and the consequential debilitation of entire populations. The incidence of malarial infection is so high in Eritrea that, along with two or three other chronic, viral, or infectious conditions such as pulmonary tuberculosis, gastro-intestinal ailments, and HIV, the economy of this nation is measurably impacted.

Agencies, both public and private, have made concerted attempts to reduce risk factors contributing to the proliferation of malaria in Eritrea. Once these risks have been identified, it then becomes essential to proceed with effective measures to eliminate or reduce them to the extent possible. Often, due to civil unrest, war and famine in Eritrea, it has become difficult to cope with endemic risks. The insert below briefly itemizes several of the major risk factors that encourage the spread of malaria throughout the nation and, consequently, increase the number of victims annually:

Although efforts have been underway in Eritrea to deal with many of these malarial risks, progress has been sporadic and irregular due to economic and political turbulence. The recent invasion of Eritrea by Ethiopia has destabilized the health infrastructure and has placed enormous stress on limited national resources. It is likely that destroyed irrigation systems, hospitals and residential instability will increase the likelihood of new epidemics of malaria and other vector-borne diseases. This is particularly true in the Southwestern region of Eritrea where malaria is present more than six months per year and where Ethiopian incursions have heavily damaged existing health facilities, homes and lifestyles.

Almost 65% of the Eritrean population have been found to be at high risk of malaria. The recent war with Ethiopia has raised havoc in efforts to control the spread of this disease that has ravaged many other East African nations as well as Eritrea. Although Ministry of Health projects and programs have done much to eradicate vectors of this disease in many urban areas, the rural populations continue to be subjected to the high risk factors discussed in this analysis. WHO, USIS and other NGOs have attempted to supplement mosquito eradication programs, and have contributed to prophylaxis efforts, but the rise in malaria figures continues to point to a rather pessimistic future for Eritrea in its struggle against this serious condition. The nation’s economy is, of course, also linked to the incidence of malaria and, for this and humanitarian reasons, the Eritrean Government must redouble its efforts to combat the proliferation of P. falciparum and P. vivax in interior and coastal areas of the nation.

Alemu, Z. " A new malaria control strategy: A new perspective", Electronic Profile, September 4, 1999. http://www.eritrea.org/EIB/Eritrea_Profile/vol06/26/EP062609049913.html

Efram, S. "National Environmental Management Plan, for Eritrea", Ministerial Council on the Environment, Ministry of Health (MOH), Asmara, 1995.

………………… "Notes on National Conference on Roll Back Malaria Movement", Ministry of Health, Electronic Profile, August 7, 1999. http://www.eritrea.org/EIB/Eritrea_Profile/vol06/22/EP062208079916.html

…………………. "Healthnet Eritrea", United States Information Service, March 1999, http://www.healthnet.org/hnet/eri.html and http://www.usaid.gov/regions/afr/leland/eriindex.htm

…………………., "Roll Back Malaria Partners", World Health Organization, April 2000. http://mosquito.who.int/cgi-bin/rbm/login_rbm.jsp, http://www.who.int/rbm/index-old-site.html and http://www.who.int/health-topics/malaria.htm