IS ELIMINATION OF MALARIA IN UGANDA STILL POSSIBLE?

In the first week of August 2019, several media outlets report- ed an increased number of malaria cases in Kampala. On 7 August 2019, the Independent newspaper reported that 5 children are admitted each day in the Acute Care Unit of Mulago National Referral hospital with convulsions and anemia due to severe malaria infection. The report drew the attention of the public to the malaria upsurge that had begun at the start of 2019. According to data by the Ministry of Health, the up- surge progressively spread affecting up to 88 districts by Au- gust 2019.

The most affected include Kisoro District which is reporting 4 times the expected case count, districts in the West Nile, and Karamoja regions. This upsurge came after the National Malaria Control Program had reported a 27% decline in malaria incidence and 52% decline in malaria deaths in 2017 (MOH, 2017).  This agreed with the 2018 preliminary findings from the Malaria Indicator Survey (MIS), which reported the prevalence of malaria in Uganda to have reduced from 19% to 9% in 2015. This is only 2% short of the 7% prevalence by 2020 tar get which would put Uganda in the malaria pre-elimination phase. Some areas such as Kampala and Kigezi reported a prevalence of less than 1%; exciting many health professionals as the goal set in the malaria reduction strategic plan (MRSP) 2015-2020 seemed tangible.

The 2014 MIS attributed this reduction in malaria prevalence to malaria interventions. These included: prompt diagnosis and treatment of malaria cases, distribution of intermittent preventive therapy to pregnant women to prevent malaria, and distribution of insecticide treated bed nets. This was coupled with social mobilization, behavior change communication, indoor residual spraying, and strengthened surveillance.

Contrary to the expectations of MoH and many health professionals, the malaria cases increased this year causing upsurges across the country. This malaria resurgence in the country threatens earlier achievements. Health facilities especially in the West Nile region have reported as high as 90% of their patients testing positive for malaria in this period. It seems like the gains achieved in the previous years are being reversed. However, this is an opportunity for Uganda to tighten the loose ends on its journey to elimination of malaria.

According to the World Health Organization (WHO), repeated infections over a prolonged period of time make people develop partial immunity allowing mild and even asymptomatic infections to occur.

However, this immunity wears off in the absence of re-infection for about 6-12 months rendering the person vulnerable to the full impact of a malarial infection once again. This is what could have happened following the much celebrated gains in the fight against malaria as documented by the preliminary findings of the MIS of 2018. The reduced transmission in the near past led to people’s immune systems “forgetting” malaria which alongside the reduced use of preventive measures like mosquito nets, might be responsible for the current increase in the number and severity of malaria this year. The latest MIS of 2018, found that the population had relaxed on the use of the malaria preventive measures in the pretext that malaria was no long- er affecting them.

Similar resurgence of malaria in areas where malaria had initially declined has been documented in areas such as China, India, and SriLanka following a failure to sustain malaria interventions. The WHO acknowledges that malaria resurgence after a marked reduction in prevalence is actually the return to a state of equilibrium which has been disturbed. For Uganda to continue with the earlier gains, there is need for continued implementation of interventions and urging the population to heed to existing malaria prevention measures. These include indoor residual spraying, destruction of potential breeding sites, consistent use of mosquito nets, Fansidar for pregnant women to prevent malaria, and seeking prompt care if infected. Ministry of health also needs to ensure continued availability of key interventions including testing, treatment, behavioral change communication, and follow-up of cases in areas with low case counts.

Even with the reducing incidence, Uganda still has a high potential for malaria transmission given the favorable climatic conditions and many sites for mosquito breeding. This resurgence should be used as an advocacy tool to propel Uganda forward to pre-elimination of malaria.