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Uganda

Malaria Control in Uganda - Towards the Abuja Targets

Disease Burden and Epidemiology

Map of Uganda

Malaria transmission is high in 90% of Uganda, with 5% of the country, mainly in the highland areas, subject to low, unstable transmission and epidemic-prone. Therefore, 93% of the total population is at risk from malaria.

Although all four species of malaria parasites exist in Uganda, Plasmodium falciparum is responsible for over 95% of cases. Major vectors are Anopheles gambiae s.l. (and within the complex mainly A. gambiae s.s.) and Anopheles funestus.

Malaria contributes to by far the major share of the disease burden in the country, with 39% of outpatient visits and 35% of inpatient admissions being due to malaria. In recent years there has been an increasing trend in clinically diagnosed malaria cases reported in the Health Management Information System (HMIS) for governmental and nongovernmental organizations [NGO] health facilities from 5 million cases in 1997 to 16.5 million cases in 2003. This translates into a 2003 incidence rate of 0.98 malaria episodes/child/years in children under 5 and 0.64 in older patients (based on HMIS data alone).

The two major reasons for this increase are thought to be 1) the abolition of user fees in the public sector resulting in increased use; and 2) increasing treatment failures due to drug resistance. Since it is known from various surveys that approximately 60-80% of fever cases are treated in the informal and private sector, these figures translate into 65 million fever cases in 2003 treated as malaria and a "true" incidence of 4.5 episodes/child/year and 1.8 for adults.

The estimated case fatality rate in 2001 was 4.1% of cases. Current estimated annual numbers of deaths from malaria are from 70,000 to 100,000. Prevalence rates for malaria parasitemia (asymptomatic) range from 50% to 80% in young children, 20% to 50% in older children and generally below 30% in adults.

The National Malaria Control Strategic Plan 2001/2-2004/5

Based on the Uganda National Malaria Control Policy (1998) and in keeping with the Health Strategic Sector Plan (HSSP) and, as part of that, the minimum health care package, the Ugandan Malaria Control Strategic Plan FY 2001/2-2004/5 states four main elements of the strategy for malaria control:

• Case management
• Vector control
• Intermittent preventive treatment in pregnancy
• Epidemic preparedness and control.

Coordination of Roll Back Malaria (RBM) Partnership

The Malaria Control Unit within the Ministry of Health - founded in 1995 - has the role of coordinating the various players in the field of malaria control. Specific structures have been designed to assist in this process, namely the Interagency Coordination Committee on Malaria (ICCM) and its four Working Groups (case management/drug policy, vector control/insecticide-treated nets (ITN), advocacy/information, education and communication (IEC) and research).

CDC, jointly with the USAID Uganda Mission supports this function by providing a technical advisor for malaria control at the Ministry of Health (MoH).

Drug Policy: From Chloroquine/Sulfadoxine-Pyrimethamine (CQ/SP) to Artemisinin-Based Combination Therapy (ACT)

Uganda established a sentinel surveillance system for antimalarial drug sensitivity testing in 1998 in the context of the East Africa Network for Monitoring Antimalarial Treatment (EANMAT) using a standard protocol according to WHO guidelines. This system has been further supported since 2002 by the Uganda Malaria Surveillance Project (UMSP), a collaboration between MoH, Makerere University, and University of California, funded by CDC. Data on resistance are complemented by studies carried out by MoH before 1998 as well as studies by other partners such as Epicentre, Medical Research Council (MRC) or German Technical Corporation (GTZ) between 1995 and 2003.

Before the year 2000 resistance testing was limited to chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) but with the change of drug policy to a CQ/SP combination therapy (designed as an interim solution and implemented in 2002) testing of single drugs was abandoned. To date results are available for the following combinations: CQ/SP, amodiaquine (AQ)/SP and artesunate (AS)/SP. One study on CoArtem® (artemether-lumefantrin) is ongoing, another is preparation and AS/AQ is currently tested at 3 sites. All data presented below refer to clinical failure rates within 14 days of follow-up in children below the age of 5 years.

• Failure rates to CQ averaged (median) 28.5% (10 sites, range 9-81%) between 1995 and 1998 and 33% (11 sites, range 7.5-56%) between 1999 and 2001.
• Respective values for SP were 5.5% (8 sites, range 3-25%) and 12% (15 sites, range 0-18%) and increased further in 2002-03 to 16% (2 sites, 9-26%).
• The combination CQ/SP was tested at 3 sites in 1999-2001 and 7 sites in 2002-2003. The median failure rates were 7% (0-12%) and 11.7% (5.5-45%) respectively.
• The AQ/SP combination was tested in 3 sites 1999-2001 and 4 sites 2002-2003, and failure rates were 1% (0-3%) and 7% (0-16%).
• AS/SP was tested in only 2 sites between 2001 and 2002, with failure rates of 1% and 2.8%.

In view of these data and the current availability of antimalarial drug options it is evident that the current first-line antimalarial treatment with CQ/SP is reaching the end of its useful life and - at least at health-facility level - the only option will be to move to an artemisinin-based combination therapy. The process of reaching broad consensus on such a new drug policy is well under way, and a final decision expected in the second part of 2004.

Home-Based Management of Fever (HBMF)

Some efforts have been undertaken by the National Program to improve health workers' knowledge and skills in the management of uncomplicated as well as severe malaria. This has been done in close collaboration with the "Integrated Management of Childhood Illnesses" (IMCI) Program.

It is recognized, however, that further interventions have to target the treatment-seeking behavior at the household level and in the private sector since all evidence shows that 50-80% of fever episodes are treated at home with drugs purchased mainly from the private sector (shops and drug shops).

As a first step, the MoH, supported by the World Health Organization (WHO), has decided to start a program of free distribution of unit-dosed, prepacked antimalarial treatments (combination of CQ/SP) for children under 5 years of age (2 sizes: 6 months to 2 years and older than 2 to 5 years) through communities and the public health sector in 10 selected districts.

So far the program has been implemented in 30 out of 56 districts. The first follow-up survey in July 2003 indicated a significant improvement in timeliness and accessibility of adequate malaria treatment in the target population with close to 60% of children under 5 in the HBMF implementation areas receiving treatment within 24 hours, and thereby reaching the Abuja target. With support from the Global Fund, implementation of HBMF will be scaled up in 2004 to reach all districts. After the start of artemisinin-based combination treatment (ACT) at health facility level, a gradual introduction of these drugs at community level is planned.

Intermittent Preventive Treatment During Pregnancy

Only recently has Uganda accepted the intermittent preventive treatment (IPT) with SP as its strategy for malaria prevention in pregnancy, recommending two doses, one between weeks 12 and 24 of pregnancy, and the second between weeks 24 and 36.

In 2002 and 2003, major efforts have been undertaken to train all health workers in government and NGO facilities in IPT and to ensure consistent supply of drug and information materials.

IPT has also been integrated into HMIS data collection. Based on these figures, the current coverage with at least 2 doses of SP is estimated at 30% in 2003. It is believed that a coverage rate of 45-50% is achievable by end of 2005.

Insecticide Treated Nets - The Focus For Malaria Prevention

Use of insecticide-treated mosquito nets (ITNs) is relatively new in Ugandan communities. Since its introduction in the country the in early 1990s, the promotion of their use has been mainly by NGOs in small efficacy trial projects covering a few populations. Surveys done in 1995 and 1996 by the African Medical and Research Foundation (AMREF) and GTZ indicate that less than 1% of the population used mosquito nets at that time.

Since then significant progress has been made in the promotion of ITNs and the establishment of a commercial market for nets as well as insecticides. In 1998 the MoH included ITNs in the national malaria policy as one of the key strategies for malaria prevention. In 1999, import tariffs as well as value-added tax (VAT) have been waived for mosquito nets and netting material. In 2002 the Uganda Bureau of Standards adopted the WHO-recommended quality standards for mosquito nets.

Most importantly, a comprehensive ITN implementation strategy was agreed upon by all stakeholders in 2003. The strategy is based on a mixed model of ITN distribution: Promotion of a commercially based distribution network is complemented by targeted subsidies for biologically vulnerable groups such as children and pregnant women and free net distribution in emergency situations (e.g. refugees, AIDS patients etc.).

This creation of a favorable environment coupled with increasing awareness and demand from the population has dramatically improved the supply side for ITNs in the country. In 2002 at least 4 commercial net and/or insecticide distributors and one social marketing project are active and selling either high quality mosquito nets bundled with a single dose of insecticide or factory pre-treated long-lasting ITNs through expanding distribution networks. The total annual sales of mosquito nets in Uganda has increased from an estimated 40,000 nets in 1999 to about 100,000 in 2000 and 250,000 in 2001, 280,000 in 2002 and 467,000 in 2003 (see figure).

Net re-treatment at community level during a recent pilot for the national campaign. (Image contributed by MoH and Malaria Consortium)

With increasing availability of nets and insecticide, the ITN coverage and utilization in Uganda have increased. Based on a number of data sources (e.g. Uganda Demographic and Health Survey (UDHS) 2000/2001, RBM base-line, Commercial Market Strategies (CMS) survey, Netmark), the proportion of households with at least one mosquito net in 2000/2001 can be assumed to vary from 15% to 45% in urban centers and from 2 to 15% in rural areas with a countrywide estimate of 12.8% (UDHS). In 2003, this rate is estimated to have increased to 25-30% in rural and 45-60% in urban areas. While net retreatment rates are currently still very low (around 10% of existing nets), it is expected to increase significantly with the availability of long-lasting ITNs (in 2003, long-lasting nets made up 50% of ITN) and the national net treatment Campaigns. It is believed that by the end of 2005 45% of children under 5 years of age will be sleeping under an ITN. This is slightly below the Abuja Target of 60%, but a large step forward for Uganda.