Uganda

Malaria facts

Uganda has the 3rd highest global burden of malaria cases (5%) and the 8th highest level of deaths (3%). [1] It also has the highest proportion of malaria cases in East and Southern Africa 23.7%. [1 ] There is stable, perennial malaria transmission in 95 percent of the country, with Anopheles gambiae s.l. and An. funestus s.l. being the most common malaria vectors. [2]

Between 2016 and 2019, the estimated number of malaria cases decreased 7.2%, from 283 to 263 per 1 000 000 of the population at risk, while deaths fell 9.5% from 0.34 to 0.31 per 1000 of the population at risk over the same period. [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]

However, in 2018 there was a lower-than-expected number of malaria cases because there was no seasonal transmission peak between week 20 and 30 as we’ve seen in previous years. This could potentially be because of the mass distribution of nets, which was completed in early 2018. [2]

In 2019, on the other hand, malaria cases increased in comparison to 2018 as the transmission peak was untypically long due to increased rains and aging of mosquito nets distributed in 2017/2018. This stresses the need to increase efforts towards maintaining gains obtained so far. [2]

Net ownership and use vary widely across sociodemographic characteristics within the regions of Uganda. Qualitative and quantitative results from household surveys, literature reviews, and field reports indicated that the main barriers for not using ITNs include problems with hanging nets, limited perceived benefit of nets, and religious beliefs, as well as myths and misconceptions among target beneficiaries. [2]

Prolonged robust and multipronged campaigns to enhance access and usage of ITNs are essential. What is more, declining ITN ownership from 90 percent in the MIS 2014-15 to 83% in MIS 2018-19 is a reminder that interventions must be maintained post-UCC and supply though routine channels must be enhanced. [2]

Progress regarding children is promising. Data from the 2018 Malaria indicator survey (MIS) revealed that 4% of children aged 6–59 months were severely anaemic in 2018 versus 6% in 2016. Furthermore, 87% of children with fever were able to seek care in 2018, an increase from 81% in 2016. [3]

The new Uganda Malaria Reduction and Elimination Strategic Plan 2021-2025, which is the result of coordinated efforts between the National Malaria Control Division (NMCD), the U.S. President’s Malaria Initiative (PMI), the World Health Organisation (WHO), the Global Fund, and other strategic partners, aims to reduce malaria infections by 50 percent, morbidity by 50 percent and mortality by 75 percent by 2025. The Plan aims to achieve these goals through stratification to ensure appropriate tailoring of intervention mixes for the various epidemiologic contexts, universal coverage of services (including in the private sector), robust data management and social behavioral change, multisectoral collaboration, and malaria elimination in two districts. [4]

Malaria transmission

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

The country experiences two malaria transmission types: [2]

  • 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.[2]

Case management

The National Malaria Control Division is currently revising the malaria case management guidelines on [2]:

  • Artemether-lumefantrine (AL) as a well-tolerated drug during the first trimester
  • Discarding monotherapies of artemether or Sulfadoxine-pyrimethamine (SP)
  • Recommendations on the correct artesunate dosing relative to age and weight
  • Agreement to conduct malaria death audits
  • Integrated Community Case Management (iCCM) in hard-to-each areas.

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 historically been low. Between 2016 and 2018, however, the proportion of pregnant women who received two of doses of intermittent preventive treatment during their last pregnancy in the last two years increased from 46% to 72%, and the proportion who received three or more doses increased from 17% to 41%. [2]

In 2018, 83% of households reported having at least one insecticide-treated bednet (ITN). This was an improvement over 2016 (78% of households) although lower than reported in 2014 (90%). Between 2016–2018, there was a slight increase in the use of mosquito nets by pregnant women (64% in 2016, 65% in 2018) and a slight decline in use by children under five years of age (62% in 2016, 60% in 2018); in both cases, usage had declined since 2014 (75% for pregnant women; 74% for children under five years of age). [2]

The new guidelines being revised by the National Malaria Control Division also includes the WHO antenatal care (ANC) recommendations of eight contacts, and starting SP at 13 weeks’ gestation.

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. In 2018, approximately 59 percent of patients reported first seeking treatment in the private sector.

Approximately 59 percent of patients first seek treatment in the private sector (MIS 2018) and 61 percent of patients with fever seek their first healthcare from the private sector (UDHS 2016/17). [2]

Gender disparities

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 ITNs 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. [6]  For severe malaria in pregnancy, intravenous artesunate is recommended as the first-line treatment and quinine as the alternative. [2] 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. [2] 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.[2]

The World Health Organisation’s Global Malaria Programme has developed an easily adaptable repository structure in District Health Information Systems [7], 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. [7]

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.

 

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.