Highland Malaria Transmission Dynamics in Space and Time Before Pre-elimination Era, Northwest Ethiopia.

The total malaria count was 5893 for 2019 compared to 31, 550 for 2020 and 33, 248 for 2021. Mean monthly malaria incidence/1000 people in 2019 was 2.39 ± 5.4 and increased to 10.64 ± 16.99 in 2020 and 11.19 ± 16.59 in 2021. Annual malaria incidence increased from 24 cases/1000 people in 2019 to 139.08 cases/1000 people in 2021 and is alarming danger in malaria elimination program in the district or the country as a whole. Poisson and Negative binomial regressions models indicated 5.78- and 5.26-fold malaria cases increase, respectively, in 2021 compared to 2019. The sudden increase in malaria incidences (counts) in 2020 and 2021 coincided with the interruption of residual insecticide application in Gondar Zuria district during the transition period towards the malaria pre-elimination stage implicating the role of malaria control tools in suppressing transmission. Study on climate variability also indicated that the rainfall variability in different months might have also favored high malaria transmission in 2020 and 2021 compared to 2019. Thus, in addition to re-starting the use of malaria control tools, giving attention to climate anomalies (variability) that favors malaria transmission, for prompt interventional actions, is required. The malaria elimination program in Ethiopia might have not reached a pre-elimination stage as malaria cases per 1000 people have not decreased below five in the majority of Ethiopian districts. Tracing, confirming, and treating individual cases to stop further transmission is, almost, impossible. In a situation like this, the Ethiopian malaria elimination program should work intensively towards understanding malaria epidemiology at the district level to re-design a localized malaria control strategy. The renewed malaria control program should also consider altitudes above 2000 m.