Over 10 million malaria cases were reported in Ethiopia in 2024, driven by rising drug- and diagnostic-resistant parasites, according to a study published in JAMA.
Ethiopia’s malaria crisis has escalated to alarming levels, with over 10 million cases reported in 2024—the highest in seven years—amid growing evidence of parasites evolving to evade both treatment and diagnosis. A study led by the Ethiopian Public Health Institute (EPHI) and the University of North Carolina at Chapel Hill found that genetic mutations linked to resistance against artemisinin-based therapies and HRP2-based rapid diagnostic tests are becoming more prevalent across the country. The findings, published in the Journal of the American Medical Association, highlight a dual threat: parasites that not only survive drug treatments but also avoid detection, undermining public health efforts.
Resistant Parasites Spread as Malaria Cases Surge
But the increasing prevalence of resistance-associated mutations underscores the importance of strengthening surveillance systems and evaluating new treatment approaches before resistance becomes a larger threat.
Drug and Diagnostic Resistance: A Dual Threat
The study identified two critical resistance mechanisms: drug resistance and diagnostic resistance. The pfk13, R622I mutation, which reduces susceptibility to artemisinin, has been detected across multiple regions. Simultaneously, deletions in the pfhrp2 and pfhrp3 genes—responsible for producing proteins targeted by HRP2-based rapid diagnostic tests—are spreading, potentially masking infections and delaying treatment. This dual resistance creates a dangerous cycle: undetected cases can persist and transmit, while failing treatments allow resistant parasites to proliferate.
Dr. Jeffrey Bailey of Brown University, who studied similar resistance patterns in Uganda, warned that new mutations are spreading so rapidly — it tells us they are important to the parasite’s survival.
His team identified a cluster of genetic variants linked to reduced susceptibility to artemether-lumefantrine (AL), the most used artemisinin-based combination therapy across sub-Saharan Africa. Our work identifies a molecular marker that could be used by surveillance studies to track the emergence and spread of reduced susceptibility to front-line malaria treatments across Africa,
Bailey said.
Ethiopia’s Response: New Tests and Surveillance
Ongoing monitoring of resistance markers will be critical to malaria treatment and control strategies,
the study’s authors emphasized.
However, challenges remain. The study found that resistance alone is unlikely to explain Ethiopia’s recent malaria resurgence, pointing to a combination of factors, including disruptions to malaria control programs and climatic changes, contributing to increased transmission. At the same time, the data suggest these mutations were not the primary cause of the recent resurgence in malaria cases,
said Jonathan B. Parr, MD, MPH, co-senior author of the study and associate professor of medicine.
Global Implications and Unanswered Questions
The findings in Ethiopia mirror broader concerns across Africa. Meanwhile, the authors note that ongoing monitoring of resistance markers will be critical to malaria treatment and control strategies.
Yet critical questions remain. How far has the resistance spread beyond Ethiopia?
As Ethiopia grapples with this dual crisis, the global health community is watching closely. The country’s experience underscores the urgent need for adaptive strategies, including new drugs, improved diagnostics, and enhanced surveillance. Without swift action, the resurgence of malaria could undo decades of progress, threatening millions of lives and economic stability across the continent.
