By Agnes Kasemiire
Malaria contributes up to 30 per cent of outpatient visits, 20 per cent of admissions and 10 per cent of deaths in Uganda.
In 2021 alone, the country recorded the third highest malaria cases in the world, with 12 million cases and 5,000 malaria related deaths, ranking Uganda eighth globally as a malaria risk country.
However, the numbers are estimated to double (to 10,000) because not all deaths in the community are recorded.
The Malaria Indicator Survey 2018-19 report cites the high malaria prevalence pockets in Uganda as Karamoja, Busoga, West Nile, Acholi and Lango.
The same report reveals that there are disparities in the prevalence of malaria across particular regions of the country.
Regions of Busoga and Karamoja are seen to have a high prevalence at about 21 per cent.
West Nile recorded a prevalence of 22 per cent. Malaria prevalence in areas of Kampala and Kigezi stands at less than one per cent.
Malaria fight 2022
Damian Rutazaana, an epidemiologist at Ministry of Health, says malaria fight in 2022 will focus on the most affected areas and groups.
Additionally, priority will be given to introduction of new tools such as the malaria vaccine.
He adds that scaling up of current tools that are effective for example mosquito nets will be conducted.
Why the disparities
Rutazaana says there are inherent issues in the regions and top on the list is poverty; and malaria is considered a disease for poor people.
As such, poor people who are not able to construct proper permanent houses, afford interventions such as buying a mosquito net or even seek treatment early when they fall sick are the major victims.
Environment is another driving factor. For example places that are warm or hotter and with more rainfall are more likely to suffer malaria than places that are cool and dry.
Kigezi and mountainous regions of Elgon are very cool, so mosquitoes cannot breed well as they would in hot areas of Pakwach.
It simply means that hotter areas provide a breeding place for mosquitoes. Although urbanisation is heavily linked to poverty, it brings services closer.
Other than people being far spaced, they come together and as a result, services such as health facilities are easier to access.
In addition, housing improves with urbanization and instead of people sleeping in makeshift houses, they reside in better houses.
Rutazaana further explains that places that are more urban are three times less likely to have malaria compared to those that are in rural setting, because of access to better health services, coupled with better housing and infrastructure of the urban areas.
Interventions such as integrated vector management have partly contributed to a reduction in the malaria prevalence indicators.
For instance every three years, long-lasting insecticidal nets are distributed to everyone throughout the country.
Recently, 28.4 million mosquito nets were received in the country. Of those, about 27.8 million mosquito nets were distributed.
The general population, with refugees inclusive, benefited from the campaign.
Children & women
Children under five and pregnant women, the elderly travelers from non -endemic countries and people with low immunity are at increased risk of severe forms of malaria.
To safeguard pregnant women from malaria and its complications, when they report for their first antenatal visit they are given a treated mosquito net to protect them against getting malaria, explains Rutazaana.
Additionally, the pregnant women are given antimalarial drugs after the first three months of pregnancy to protect them against malaria.
“When expectant mothers get malaria, they are at high risk of getting the severe form and deaths, but also losing the child through stillbirth or getting underweight babies,” says Dr Joseph Kafuuma, a medical officer at Women’s Hospital International and Fertility Centre, Bukoto, Kampala.
Children under the age of five are also prioritised because they are also at risk.
As such, during the routine immunisation they are given the long-lasting insecticide nets.
Data reveals that 25 per cent of the population are children, and when they get malaria it usually progresses to severe form because their immunity is not well built.
Indoor residual spraying, where the inside of houses is sprayed with quality assured insecticide has been conducted in 16 districts of Eastern and Northern Uganda.
These include: Serere, Palisa, Kibuku, Budaka, Butaleja, Bugiri, Tororo, Namutumba, Amolatar, Dokolo, Kalaki, Kaberamaido, Lira, Otuke, Amolatar and Alebtong.
According to Ministry of Health, this year West Nile districts of Adjumani, Arua, Nebbi, Moyo, Terego, Obongi, Madi-Okollo, Yumbe, Nebbi, Pakwach, will receive indoor residual spray services. Maracha and Nebbi districts, which previously received, will be added.
Larva source management is another intervention that has been done on a small scale in districts of Kabaale and Lira.
However, Rutazaana is optimistic that as more resources are availed the intervention will be scaled up.
The intervention deals with mosquitoes in stagnant water, where communities are encouraged to fill stagnant water sources with soil.
In addition, breeding sites of mosquitoes are destroyed by applying a chemical which kills the larvae stages.
He further explains that provision of quality treatment and diagnostic services for people with malaria is another milestone to celebrate.
As such, people suffering from malaria can be tested early and also access anti-malarial medicines.
As such, health facilities are availed with anti-malarial medicines, both for simple and severe malaria.
In addition, malaria rapid diagnostic tests have been availed to public and private nonprofit health facilities, to reduce the long queues at major health centres.
For the private facilities, the procurement of anti-malarial medicine has been subsidised to enable the public access it at a cheaper cost.
Rutazaana further explains that because malaria takes away many critical hours of study from school going children, hence hampering their education, the Health Ministry has embarked on giving children in schools long lasting insecticide nets.
The ministry monitors the efficacy of antimalarial drugs every year. Upon detecting increased resistance, a recommended drug is changed.
This was the case when the country switched from use of Sulphadoxine Pyrimethamine commonly known as Fansidar to Artemesinin-based combination therapies.
Rolling out the vaccine
In October 2021, World Health Organization (WHO) recommended widespread use of the RTS,S/AS01 (RT,S) (Mosquirix) malaria vaccine for children at risk in Sub-Saharan Africa and in other regions with moderate to high malaria transmission.
The recommendation was based on the results from on-going pilot programme in Ghana, Kenya and Malawi that has so far reached more than 800,000 children since 2019.
Children under five years are a priority because they are the most vulnerable group to dying from malaria.
For Uganda, the Ministry of Health is working with international partners such as WHO, GAVI and Global Fund to mobilize resources to roll out the malaria vaccine in the next three years.
How the vaccine works
The vaccine contains a small part of the malaria parasite, which is produced as a synthetic protein.
This protein is coupled with a molecule designed to stimulate strong immune response.
So, the vaccine mainly stimulates the body to make antibodies against the malaria parasite, by neutralizing and preventing it from entering liver cells, which are the first cells the parasite affects when it enters the body.
However, the level of protection provided by the vaccine is not ideal. It varies with the age of children.
In older children (5-17) months, it is averaged at 36 per cent protection against developing clinical malaria over a four year-period.
Protective immunity also reduces over time, meaning regular booster doses will be required.
But overall, the vaccine is expected to make a significant contribution to malaria control in high risk areas, alongside other control measures.