In Ethiopia, malaria transmission is seasonal and epidemic-prone, with both Plasmodium
falciparum and Plasmodium vivax being endemic. Such spatial and temporal clustering of
malaria only serves to underscore the importance of regularly collecting up-to-date malaria
surveillance data to inform decision-making in malaria control and improve responsiveness to
potential epidemics.
This thesis compares indicators and strategies used for the monitoring and surveillance of
malaria in Ethiopia. Cross-sectional school-based surveys were conducted throughout Oromia
Regional State, generating data on malaria prevalence by microscopy, risk factors for
infection and intervention use. Filter paper blood samples collected during these school
surveys were subsequently tested to determine exposure to malaria based on presence of
anti-Plasmodium antibodies, and Bayesian geostatistical modelling was employed to predict
P. falciparum and P. vivax seroprevalence across Oromia. In southern Ethiopia, a schoolbased
syndromic surveillance system was piloted, exploring the utility of school absenteeism
as a complementary indicator of malaria epidemics at community level. Finally, findings from
the school surveys, measured and modelled seroprevalence, as well as data from the national
Malaria Indicator Survey in 2011 were compared with spatially congruent estimates of
malaria incidence collected from health facilities and to modelled parasite rate from the
Malaria Atlas Project.
Findings from this thesis demonstrate the limitations of microscopy as a primary indicator of
malaria infection in cross-sectional surveys in areas of very low transmission. The work
highlights the potential of serological indicators of Plasmodium exposure for inclusion in
periodic large-scale malaria monitoring activities and develops a first ever geostatistical risk
map based on serological indictors. This was supported by comparative analysis of a range of
survey and modelling indicators against estimates of incidence from passive surveillance,
indicating the inadequacy of cross-sectional surveys estimating population parasitaemia to
reflect the spatial extent and temporal variability of transmission. The piloted syndromic
surveillance system indicates that monitoring school absenteeism has potential as a
complementary epidemic alert system, operating alongside the existing system at health
posts, but is limited by low school enrolment in the piloted setting.
The findings of this thesis indicate that existing periodic monitoring strategies and tools are
insufficient to fully describe the extent of malaria in settings where Plasmodium transmission
is spatially and temporally variable. Modifications to monitoring strategies are
recommended, including incorporation of serological indicators and spatial modelling
