As Uganda continues with the ongoing Malaria vaccination, there are key facts for everyone to know.
According to officials from the Ministry of Health, Uganda remains a high-burden malaria country, with its entire population of 45.5 million at risk of being infected with malaria.
Vulnerable groups include pregnant women and children under five, with the highest transmission areas being northern Uganda (Acholi, Karamoja, Lango, and West Nile regions) and eastern Uganda (Busoga region).
As of 2022, Uganda had the 3rd highest global burden of malaria cases (5.1%) and the 8th highest level of deaths (2.9%). It also had the highest proportion of malaria cases in East and Southern Africa, accounting for 23% in 2022.
Between 2021 and 2022, the estimated number of malaria cases increased by 1.6% from 263 to 268 per 1000 of the population at risk, while deaths fell 2.3% from 0.38 to 0.37 per 1000 of the population at risk over the same period.
There is stable, perennial malaria transmission in 95% of the country, with Anopheles gambiae and An. funestus being the most common malaria vectors.
To accelerate progress towards global malaria targets, the WHO and RBM Partnership rolled out the High Burden High Impact approach in 10+1 countries which include Uganda.
The Uganda Malaria Reduction and Elimination Strategic Plan (UMRESP) 2021-2026 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, social and behavioural change, multisectoral collaboration, and malaria elimination in two districts.
Although the entire population is at various levels of risk, marginalised populations are confronted with economic, social, and contextual challenges and barriers that may limit their access to malaria prevention, treatment, and control programmes.
These populations include vulnerable and underserved populations such as:
- Children under five years and pregnant women
- People living with HIV
- People with disabilities
- Inmates and other detainees
- People in closed/congregate settings
- Migrant and mobile populations
- Internally displaced populations
- Refugees and asylum seekers
- Older persons
- People affected by ethnic, geographical or cultural barriers.
To address the human rights barriers, Uganda has developed a comprehensive strategy document aimed at a malaria-free Uganda through protecting human rights, achieving gender equality, and improving health equity for all Ugandans in all their diversity – The plan is entitled: “Leaving no one behind: A national plan for achieving equity in access to HIV, TB and Malaria services in Uganda, 2020-2024.”
Malaria transmission
Plasmodium falciparum accounts for 97% of infections; both P. vivax and P. ovale are rare and do not exceed 2% of malaria cases in the country. [4]
The country experiences two malaria transmission types: stable, perennial malaria transmission which exists in 90–95% of the country, and low, 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.
To guide the deployment of interventions, the country has been stratified into three strata, based on epidemiologic, entomologic and socio-behavioral characteristics:[4]
- Very low burden areas (<2% malaria prevalence) about 2.4% of the population
- Urban cities (6.2m; 14.4% of total population)
- High burden (rest of the country) areas.
Case management
For severe malaria, intravenous or intramuscular artesunate is the recommended treatment for all adults and children.
When artesunate is not available, parenteral artemether or quinine can be used. Once a patient is able to tolerate oral medication, and after at least 24 hours of parenteral therapy, treatment should be completed with a full course of an oral first-line artemisinin combination therapy (ACT).
For pre-referral intervention before transfer to an appropriate level of care, a single intramuscular dose of artesunate, intramuscular artemether, or intramuscular quinine can be used.
At the community and lower-level health facilities, or where injections are not available, a single dose of rectal artesunate can be used as pre-referral intervention for children under six years of age only.
Malaria in pregnancy
Uganda has adopted the WHO guidelines for Intermittent preventive treatment in pregnancy (IPTp), which includes a treatment dose of sulfadoxine-pyrimethamine (SP) for HIV negative women at each scheduled antenatal care (ANC) visit starting at 13 weeks gestational age, with a minimum of four weeks between doses, and a recommended minimum of three doses (IPTp3).
SP is recommended to be administered as directly observed therapy (DOT).[3] The national MIP guidelines was updated to reflect the revised 2022 WHO malaria treatment guidelines that recommend the use of artemether-lumefantrine (AL) for uncomplicated malaria in all trimesters of pregnancy, including the first trimester. Parenteral artesunate continues to be the recommended first-line treatment for severe MIP.
Between 2019 and 2022, the proportion of pregnant women who received three or more doses increased from 40% to 62% which is below the coverage goal in the UMRESP 2021–2026 for MIP of at least 85 percent of all pregnant women.
Over the same period, there was a slight increase in the use of mosquito nets by pregnant women (64% in 2016, 65% in 2018).[3]
Seasonal Malaria Chemoprevention
The National Malaria Control Division (NMCD), in collaboration with Malaria Consortium and funded by the Bill & Melinda Gates Foundation, conducted a pilot SMC project consisting of five cycles among children aged 3–59 months in two districts from May to September 2021.
This was increased to eight districts in 2022 and then nine in 2023 from May and ended in September. About 277,000 children were targeted. The coverage rate for 2023 was 86.6%.
The primary challenge encountered was the considerable cost of providing SMC. To address this issue, SMC is now conducted over three days instead of four, the number of supervisors has been reduced, and stocks are delivered for the entire round instead of by cycles.
The NMCD is committed to further engaging with districts to boost their contribution to SMC and will persist in innovating to identify additional avenues for decreasing the cost of SMC.
Insecticide-treated nets
Ownership of at least one ITN has generally increased over time. Households owning at least one ITN increased from 47% in 2009 to 83% in 2018–2019 (MIS).
Full household ITN coverage, as measured by the percent of households with at least one ITN for every two people in the household, increased from 16% in 2009 to 54%in 2018–2019.
Uganda conducted a mass ITN coverage campaign from June 2020 to March 2021. The ITN ownership (households owning at least one ITN) levels nationally were estimated to increase to at least 90%.
ITN use by children increased from 33% in 2009 to 60 % in 2018–2019. The use of ITNs by pregnant women increased from 44% in 2009 to 65% in 2018–2019. However, between 2016 and 2018–2019, there was a slight decline in ITN use among children under five years of age over the same period (62% to 60%) (MIS 2018-2019).
Gender disparities
Gender-based disparities and social customs have created hurdles to accessing malaria-related services. A key example of this is that health-seeking decisions are often taken by male family heads 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 the attainment and maintenance of universal coverage of bed nets.
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.
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.
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.
The World Health Organisation’s Global Malaria Programme has developed an easily adaptable repository structure in District Health Information Systems , 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 the Gambia, Ghana, Mozambique, Nigeria, Uganda and the United Republic of Tanzania.
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 in 2021 322 Community Health Extension Workers (CHEWs) were trained and graduated in 2022.
They play a critical role in delivering malaria literacy, diagnosis, and treatment at the community level.
Additionally, 334 Village Health Team (VHT) members were trained in integrated community case management (iCCM) and supply chain management.