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Malaria Stratification, Climate, and Epidemic Early Warning in Eritrea

Eritrea has a successful malaria control program, but it is still susceptible to devastating malaria epidemics. Monthly data on clinical malaria cases from 242 health facilities in 58 subzobas (districts) of Eritrea from 1996 to 2003 were used in a novel stratification process using principal component analysis and nonhierarchical clustering to define five areas with distinct malaria intensity and seasonality patterns, to guide future interventions and development of an epidemic early warning system. Relationships between monthly clinical malaria incidence by subzoba and monthly climate data from several sources, and with seasonal climate forecasts, were investigated. Remotely sensed climate data were averaged over the same subzoba geographic administrative units as the malaria cases. Although correlation was good between malaria anomalies and actual rainfall from ground stations (lagged by 2 months), the stations did not have sufficiently even coverage to be widely useful. Satellite derived rainfall from the Climate Prediction Center Merged Analysis of Precipitation was correlated with malaria incidence anomalies, with a lead time of 2–3 months. NDVI anomalies were highly correlated with malaria incidence anomalies, particularly in the semi-arid north of the country and along the northern Red Sea coast, which is a highly epidemic-prone area. Eritrea has 2 distinct rainy seasons in different parts of the country. The seasonal forecasting skill from Global Circulation Models for the June/July/August season was low except for the Eastern border. For the coastal October/November/December season, forecasting skill was good only during the 1997–1998 El Niño event. For epidemic control, shorter-range warning based on remotely sensed rainfall estimates and an enhanced epidemic early-detection system based on data derived for this study are needed.

Received August 21, 2006. Accepted for publication April 16, 2007.

Acknowledgments: We thank the Minister of Health for Eritrea, Mr. Saleh Meky, the Director General for Health, Mr. Berhane Tensae, and the head of Disease Prevention and Control, Dr. Goitom Mebrahtu, for their support. We are very grateful to Kiros Sereke, Afwerki Araia, Andemariam WeldeMicael, Solomon Neguse, Meles GhebreYesus, Asrat GhebreLul, Mehari Zerom, Asmelash Gegziabher, Helen Fekadu, Solomon Mengistu, Yohannes Bein, David Sintasath, and Dr. Josephat Shililu of the NMCP and Ezra Kidane, Amanuel Kifle, and Samuel Goitom from the NHMIS. We thank Matthew Lynch of USAID, Lisa Lukang of CIESIN, and Tsegay Wolde-Georgis of IRI for input and support, and also the National Statistics and Evaluation Office, Asmara, Eritrea, and the Water Resources Department, Ministry of Lands, Water and Environment, for provision of GIS data.

Financial support: This study was funded by the USAID Environmental Health Project, Contract HRN-1-00-99-00011-00 sponsored by Office of Health, Infectious Disease and Nutrition, Bureau for Global Health, USAID, Washington, D.C. 20523. The following organizations supported the malaria control program of Eritrea during the period of study: The World Bank HAMSET project; USAID; WHO; Italian Cooperation; UNICEF.

^* Address correspondence to Pietro Ceccato, International Research Institute for Climate & Society, The Earth Institute at Columbia University, Lamont Campus, Palisades, NY 10964-8000. E-mail: pceccato{at}iri.columbia.edu

Authors’ addresses: Pietro Ceccato, Anthony Barnston, John del Corral, Stephen J. Connor, and Madeleine C. Thomson, International Research Institute for Climate and Society (IRI), The Earth Institute at Columbia University, Lamont Campus, 61 Route 9W, Palisades, NY 10964-8000, Telephone: +1 (845) 680 4413, Fax: +1 (845) 680 4864, E-mail: pceccato{at}iri.columbia.edu. Tewolde Gebremeskel, National Malaria Control Program, Ministry of Health, Asmara, Eritrea. Malanding Jaiteh and Marc Levy, Center for International Earth Science Information Network (CIESIN), Columbia University, New York, NY. Patricia M. Graves, EpiVec Consulting, 606 Kimberly Lane NE, Atlanta, GA 30306, Telephone: +1 (404) 293 3529, Fax: +1 (770) 488 4258, E-mail: epivec{at}comcast.net. Shashu Ghebreselasssie and Andom Ogbarmariam, Department of Research and Human Resources, Ministry of Health, Asmara, Eritrea. Issac Fesseha, Civil Aviation Authority, Meteorological Services, Asmara, Eritrea. Eugene Brantly, RTI International, One Metro Center, 701 13th Street, NW, Suite 750, Washington, D.C. 20005.

Reprint requests: Pietro Ceccato, International Research Institute for Climate & Society, The Earth Institute at Columbia University, Lamont Campus, Palisades, New York 10964-8000, Telephone: +1 (845) 680 4413, Fax: +1 (845) 680 4864, E-mail: pceccato{at}iri.columbia.edu.

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