Uganda

Uganda malaria facts

Uganda has the 3rd highest global burden of malaria cases (5%) and the 7th highest level of deaths (3%).1 It also has the highest proportion of malaria cases in East and Southern Africa 23.7%.1 Between 2017 and 2018, the country made significant strides and was able to reduce case numbers by 1.5 million (11%).1 This may have been be as a result of a successful rapid public health response to the almost 25% increase in cases that was reported between 2016 and 2017.  

The estimated number of malaria cases was about 22% higher than 2015 levels, from 236 to 289 per 1000 of the population at risk, while deaths fell by about 7% versus 2015 levels from 0.33 to 0.31 per 1000 of the population at risk.1

In 2017, malaria accounted for 27-34 % of outpatient visits and 19-30 % of inpatient admissions.  Under-five deaths due to malaria was at 7% while neonatal (under 12 months) mortality was at 11%.2

Progress regarding children is however mixed. Data from the 2016 District Health Survey (DHS) revealed that 6.1 % of children aged 6-59 months were severely anaemic versus 4.6 % in 2014. Positively, over 82% of children with fever were able to seek care.2

Malaria transmission

P. falciparum accounts for 98% of infections while both P. vivax and P. ovale are rare and do not exceed 2 % of malaria cases in the country.6

The country experiences two malaria transmission types:6
-    Stable, perennial malaria transmission which exists in 90–95 % of the country 
-    Low and unstable transmission with potential for epidemics in 5-10% of the country. 

Transmission peaks are aligned with the two annual rainy seasons which take place from March to May and from September to November.6 

Malaria in pregnancy

Although prevalence of exposure to malaria infection during pregnancy was 30% or more and maternal anaemia exceeded 40%,  protection against malaria during pregnancy has been low: The proportion of pregnant women who received two of doses of intermittent preventive treatment during their last pregnancy in the last two years was at 45% for 2017.6 According to the 2016 DHS data only 8% of pregnant women received three doses of IPTp in comparison to 17.2% recorded by the 2014-2015 MIS survey.6

In 2018, over 80% of the population at risk also reportedly used long-lasting insecticidal nets (LLINs). This is a significant improvement over 2016/2017 levels where overall use of mosquito nets declined from 74% to 62% for children under five years of age and from 75% to 64% for pregnant women.6

Health services administrative levels

There are four levels of health administration: national, regional, district and county. Uganda counts among the countries where care seeking in private sector facilities is among the highest with 45% of the population seeking care from private sector facilities.6

Malaria diagnostic testing has improved in the country and 71 % of the reported malaria cases were laboratory confirmed in comparison to 60% in 2016.6

Curtailing an epidemic

Gains made towards malaria control are however threatened by a recent resurgence, especially in Northern Uganda.5

Following the withdrawal of IRS from the region in 2012, there was a large malaria upsurge (up to a 20-fold increase) from April 2015, especially in the 11 districts where there had previously been IRS in comparison to the period when spraying was being implemented.5

Several interventions have been adopted to mitigate the issue. These include case and fever management, referral systems’ strengthening, ensuring availability of essential commodities, behavioural and change communication change, technical support to affected districts, health worker training, allocation of national buffer of anti-malarials to affected districts, as well as IRS and LLIN distribution to curtail the epidemic. Since then, there has been a drastic decline in the burden of malaria.5

Gender-based disparities and social customs have also created hurdles for accessing malaria related services. A key example of this is that health seeking decisions are often taken by male family heads of family and this could lead to delays in seeking treatment. In addition, there are instances where only men are sleeping under LLINs at the expense of children or pregnant women. Steps to tackle these challenges include attainment and maintenance of universal coverage of bed nets.5

Survey data also reveals that severe anaemia (mostly due to malaria) continues to be a public health problem in Uganda. For severe malaria in pregnancy, intravenous artesunate is recommended as the first-line treatment and quinine as the alternative.6 All malaria in pregnancy cases are noted in antenatal care registers and reported in health management information system platforms such as District Health and Information Systems databases.6 The Integrated Management of Malaria curriculum includes management of uncomplicated and severe malaria, management of malaria in pregnancy, and parasite-based diagnosis with rapid diagnostic tests or microscopy, including how to manage a patient with fever and a negative rapid diagnostic test (RDT) or microscopy result.6

The World Health Organisation Global Malaria Programme has developed an easily adaptable repository structure in District Health Information Systems2, with guidance on relevant data elements and indicators, their definitions and computation to cover key thematic areas. So far, work to develop these databases has started in Gambia, Ghana, Mozambique, Nigeria, Uganda and the United Republic of Tanzania.1

Malaria Training

Health workers at all levels (including the private sector) were trained in integrated management of malaria (IMM) in 102 of 112 districts (10,500 HWs), including training in the management of severe malaria. Clinical audits for severe malaria were performed in 34 of 112 districts. 

Inpatient and mortality rates

Severe malaria distribution

 

    Menaces

    • Threats:
      • Changing weather patterns (i.e. El Nino)  
      • Lack of emergency preparedness and response funding 

    Severe malaria policy and practice

    National treatment guidelines
    Recommendation Treatment
    Strong IV artesunate
    Alternative IV quinine
    Alternative IM artemether
    Recommendation Pre-referral
    Strong Rectal artesunate
    Alternative IM quinine

    * During the first trimester pregnancy, the most effective anti-malarial medicine should be used under medical supervision as the major objective in treatment of severe malaria is to prevent death.