Marie Gorreti Zalwango

BHUN (MaK); MPH (MaK)
Email: mzalwango@musph.ac.ug, gorretezalwango@gmail.com
Telephone: +256 752610802/+256 789192527

Host Site: National Malaria control Division, Ministry of health

Host Mentor: Dr. Opigo Jimmy/Dr. Gerald Rukundo

ABOUT THE FELLOW

Marie Gorreti Zalwango is a field epidemiology fellow with special interest in Malaria surveillance and disease emergency preparedness and response. She holds a Master of Public Health and a Bachelor of Science in Nursing. Before joining the fellowship programme, she worked with Baylor Uganda and Mildmay Uganda where she implemented projects in HIV prevention and Maternal, Neonatal and Child Health.

During the fellowship, she was attached to the National Malaria control Division, Ministry of health. where she conducted weekly surveillance for malaria, reviewed data and made recommendations to improve malaria control and treatment interventions, conducted mentorships and support supervisions, contributed to writing of weekly malaria bulletins and review of malaria epidemic surveillance and response guidelines. She has further responded to a number of public health emergencies and authored several documents that demonstrate her advanced scientific writing skills, including bulletin articles, newspaper articles, and manuscripts which enhanced her writing skills.

  Achievements at the Host Site

• I supported publication of weekly and quarterly malaria bulletins which are used as information sources for decision making at national and subnational levels for malaria control and response interventions.
• I have been involved in supporting the routine weekly analysis of malaria epidemic surveillance to monitor upsurges in malaria cases through the construction of district malaria normal channels using weekly reported DHIS2 data. Information from this analysis was disseminated through weekly malaria status update bulletins to all international and national malaria stakeholders to guide decision making for malaria control in the country.
• I provided consultancy services to the USAID during the baseline assessment for the PMI Uganda-malaria reduction activity (PUMRA) where I led the team in Eastern Uganda. The assessment provided the current status of malaria control strategies in the supported regions and guidance for improved implementation of the activity.
• As part of the malaria incident management team, I attended daily meetings with the incident management team (IMT) to improve malaria epidemic response in the country.
• I conducted a review of malaria epidemic detection methods in Uganda which revealed granularity in district malaria transmission levels from the assigned regional transmission levels requiring stratification of malaria transmission to the lowest level possible. Furthermore, the analysis revealed that the 75th percentile method was as sensitive as the C-SUM method in low and very low transmission levels an indication that there was no need to use a different method for those regions from the nationally adopted 75th percentile method that was previously discouraged for low and very low transmission areas. Additionally, epidemic weeks detected by the 75th percentile were significantly different from those detected by the mean+2SD in medium and high transmission areas with the 75th percentile detecting more outbreaks. We
• recommended use of the 75th percentile method for all transmission areas to detect malaria outbreaks and use of the mean+2SD to guide prioritization of epidemic districts for response in absence of adequate resources.
• This analysis triggered the review of malaria epidemic surveillance and response guidelines an activity I fully participated in as a rapporteur. The review team included WHO regional and national officials, Ministry of Health – National malaria control Division team, Incident management team and other malaria stakeholders in the country. Following review of the guidelines, I participated in the drafting of standard operating procedures for the implementation of the revised manual which are to be disseminated to all districts and malaria stakeholders in the country.
• I further conducted a descriptive study on trends and distribution of severe malaria trends in Uganda from 2017-2021. Findings revealed a non-significant reducing trend in the proportion of malaria cases that are severe. This finding threatens achievement of near zero malaria deaths target by 2030 hence the need to rethink current strategies. However, some regions like Tooro and Karamoja had significant decreases; studies in these regions could provide factors associated with the decline for scaleup to other regions.
• I led a team that investigated severe malaria deaths in Namutumba District in 2022. This activity revealed under-reporting of malaria deaths in the DHIS2 system. Furthermore, we conducted a case control study to identify risk factors for deaths among children with severe malaria. Findings showed that failure to receive blood transfusion among anaemic children, failure to reach a high-level health facility referred and stock outs of antimalarials were associated with severe malaria deaths.
• Following the study on severe malaria deaths and the observed underreporting in the national health information system, I Implemented a quality improvement project to improve malaria mortality reporting in Namutumba District. The project was implemented at Nsinze HCIV and Namutumba HCIII. Basic interventions for this change were: training, mentorship and supervision of staff and frequent data reviews. The project improved accuracy of malaria mortality data (malaria deaths recorded and reported in DHIS2) from 0% in October 2022 to 100% in March 2023.
• Following study findings of blood shortage as a factor for severe malaria deaths, I published a newspaper article to create awareness on the need for blood products and to sensitize communities to donate blood. This was titled:’ Donate blood: contribute to reduction of malaria deaths in the country”. I also published a newspaper article titled: “Malaria prevention and treatment should be taken more seriously” and this was aimed at creating awareness of the seriousness of malaria infection.
• As part of the response and surveillance team at the host site, I supported a team that investigated black water fever in Kakumiro District. The team revealed that black water fever was associated with self-medication for malaria and use of multiple drugs for malaria management.
• Following the black water fever investigation, I conducted an epidemiological study to identify risk factors for self-medication for malaria in Kakumiro District. This was a household survey conducted in 8 randomly selected villages. Of the 592 participants interviewed, 368 (62%) had self-medicated for malaria in the past 6 months. Self-medication for malaria was significantly associated with being ≥35years AOR: 1.77; 95%CI: 1.04-3.01; long distance to the health facility AOR: 3.05; 95%CI: 2.09-4.47 and storage of antimalaria drugs at home AOR: 2.21; 95%CI: 1.36-3.59. Experiencing ≥6 malaria episodes in the household was protective AOR: 0.39; 95%CI: 0.23-0.65.
• I further conducted a study to describe trends and social demographic factors for malaria mortality in a population-based cohort in Eastern Uganda, 2007-2022. This was conducted in Iganga and Mayuge health demographic surveillance system site.

Fellowship program specific achievements

Surveillance data analysis

• • Reviewed data and conducted descriptive studies:
  • Severe malaria trends in Uganda, a descriptive analysis for 2017-2021
  • Evaluation of malaria outbreak detection methods, Uganda, 2022
  • Trends and social demographic factors for malaria mortality in a population-based cohort in Eastern Uganda, 2007-2022

• Quality improvement project

• • Implemented a quality improvement project to improve malaria mortality reporting in Namutumba District. The project was implemented at Nsinze HCIV and Namutumba HCIII from October 2022 to March 2023.

• HIV Project

• • Compare medical electronic records (MER) data and individual-level data from facilities to determine the correlation between Antiretrovirals (ARVs) dispensed and the number of patients in HIV chronic care in Luwero District, Central Uganda. The study revealed variations between MER and facility data across quarters with major discrepancies observed for Bombo H/C III. There were notable differences in the ARV drugs dispensed at facility level and those captured in MER data ranging from -100% to 325,256%. All health facilities had over stock with more than 100 months of stock for 1 or more drugs. Expired ARV drugs were observed at private not for private health facilities. We recommend accurate reporting of HIV positive patients in care (TX-CURR) and antiretrovirals (ARVs) dispensed data for the MER system to better inform decision making and regular stock monitoring and ARV drug and timely redistribution to ensure easy access to clients and to prevent expiries.

• Epidemiological studies

• • Did an epidemiological study to determine risk factors for death among children with severe malaria in Namutumba District, Eastern Uganda, September 2021 – February 2022
  • Factors associated with self-medication for malaria among communities in Kakumiro District, Western Uganda, 2023

• Response to public health emergencies

• •  Team lead for the investigation of severe malaria deaths in Namutumba District, Eastern Uganda in April 2022. Investigation findings were presented to the district health Office, Incident Management Team (IMT) and National Task Force (NTF) meetings

• Co-investigated

• • Black water fever investigation in Kakumiro District, August 2022
  • Crimean–Congo hemorrhagic fever outbreak investigation in Rakai and Lwengo districts, Uganda, July 2022
  • Ebola outbreak investigation in Mubende, Kassanda and Jinja districts, Uganda in October and December 2022. Following response, I conducted a study to assess stigma among Sudan Ebola Virus Disease survivors in Mubende and Kassanda Districts, Uganda, 2022. This was aimed to improve the well-being of Ebola survivors and to identify strategies for prevention of stigma among Ebola survivors in future outbreaks.

• Trainings/workshops participated in/ facilitated

• • During the AFENET 2023 conference in Mombasa-Kenya, I supported the training of participants on 7-1-7 agenda during the pre-conference workshops. This training was aimed to strengthen improved disease detection, notification and response in Africa
  • I participated in the dissemination of findings on the for the EVD population connectivity across boarders (PopCAB) conducted at Lwakhakha boarder in Namisindwa District. The event was organised by the Ministry of Health Uganda (MoH) with support from CDC and Baylor Uganda, however, data collected during POPCAB activities had never been analysed and reported on by the ministry of heath team
  • I participated in the training and mentorship of frontline tier trainees cohort 19 and 22. The trainings were held in Jinja and Lira
  • • Participated in scientific writing workshop held in Jinja from 5th – 9th December where I attained skills on scientific writing most especially manuscript writing
  • • On November 25th 2022, I presented findings from my descriptive project on malaria epidemic surveillance to the malaria scientific advisory committee to inform improved epidemic surveillance, preparedness and response. Findings informed critical questions on malaria epidemic detection in Uganda

• Conference presentations and awards

• • Oral presentation: 2nd Conference on public health in Africa held in Kigali, Rwanda from December 12th-15th, 2022. I presented: “Risk factors for death among children with severe malaria in Namutumba District, Eastern Uganda, September 2021 – February 2022”. I was privileged to win the best oral abstract presentation award.
  • Oral presentation: Participation during the 17th JASHC conference that took place at Entebbe Resort Hotel from 20th – 22nd September 2023. At this conference I presented 2 abstracts through oral presentation
  • Oral Presentation: 8th AFENET Conference held in Mombasa Kenya from 5th-10th November, 2023. I presented; “Super-spreaders as drivers of the Sudan ebolavirus disease outbreak, Uganda, 2022
  • Oral Presentation: 8th and 9th NFEC Conferences held at Hotel Africana, Kampala, Uganda 2022 and 2023. I presented 3 abstracts in both conferences
  • Poster presentation: 8th AFENET Conference held in Mombasa Kenya from 5th-10th November, 2023. I presented 2 abstracts; “Severe malaria trends in Uganda, a descriptive analysis for 2017- 2021” and “Evaluation of malaria outbreak detection methods, Uganda, 2022”.
  • Poster presentation: 3rd Conference on public health in Africa held in Lusaka, Zambia from November 27th-30th, 2023. I presented, “Stigma among EVD survivors in Mubende and Kassanda districts Uganda, 2022”.

• Written Communication
• Newspaper articles

• • “Donate blood: contribute to reduction of malaria deaths in the country”. This article aimed to create awareness on the need for blood products and to sensitize communities to donate blood
  • “Malaria prevention and treatment should be taken more seriously”. This was aimed at creating awareness of the seriousness of malaria infection
  • “Your role in elimination of mother to child HIV transmission” aimed to increase awareness on personal and community responsibility to the achievement of zero new malaria infections in the country.

• Bulletin articles

• • Editor of Uganda Public Health Bulletin (UPHB) Quarterly Epidemiological bulletin, Volume 7/Issue 3/ July- September, 2022 and also published the following articles:
  • Risk factors for death among children with severe malaria in Namutumba District, Eastern Uganda, September 2021 – February 2022: UNIPH Quarterly Epidemiological Bulletin, volume 7, issue 4, 2022
  • Trends and Distribution of Severe Malaria Cases, Uganda, 2017-2021: A Descriptive Analysis of the Health Management Information System Data: UNIPH Quarterly Epidemiological Bulletin, Volume 8 issue 2, 2023
  • Stigma among Sudan Ebola Virus Disease survivors in Mubende and Kassanda Districts, Uganda, 2022: UNIPH Quarterly Epidemiological Bulletin, Volume 8 issue 3, 2023
  • Evaluation of malaria outbreak detection methods, Uganda, 2022: UNIPH Quarterly Epidemiological Bulletin, Volume 8 issue 4, 2023
  • Improving the reporting for malaria deaths through quality improvement approaches in Namutumba District, Uganda, 2022—2023: UNIPH Quarterly Epidemiological Bulletin, Volume 8 issue 4, 2023

• Bulletin highlights and events

• • Uganda PHFP Shines at the 2nd International Conference on Public Health in Africa (CPHIA) held at Kigali Convention Centre in Rwanda on 13th – 15th December 2022
  • The Launch of indoor residual spraying in west Nile region, Uganda, 8th September 2022
  • Regional Population Connectivity Across Boarders (PopCAB) training of trainers Uganda, Kenya and Rwanda, 19th-23rd September 2022
  • Training on incident management system for malaria epidemics in Uganda, Golf Course Hotel, Kampala, 7th-10th February, 2023
  • 16th Joint Annual Scientific Health (JASH) Conference held at Munyonyo Hotel on 21st—23rd September 2022
  • World AIDS Day, 1st December 2022

Manuscripts

• Lead author

• • Risk factors for severe malaria deaths among children in Ivukula Subcounty, Namutumba District
  • Severe malaria trends in Uganda, a descriptive analysis for 2017-2021
  • Evaluation of malaria outbreak detection methods, Uganda, 2022
  • Stigma among EVD survivors in Mubende and Kassanda districts
  • Improving the reporting for malaria deaths through quality improvement approaches in Namutumba District, Uganda, 2022— 2023
  • Factors associated with self-medication for malaria among communities in Kakumiro District, Western Uganda, 2023

• Co-author on 14 other manuscripts.
• Other fellowship activities

• • Participated in the population connectivity across boarders (PopCAB) Ebola virus disease activity conducted at Lwakhakha boarder in Namisindwa District to inform ebola response.
  • Participated in the review of malaria epidemics surveillance and response guidelines and the drafting and finalisation of the malaria epidemic surveillance and response SOPs for dissemination to all stakeholders.

Summary of Epidemiological Study: 

 Title: Risk factors for death among children with severe malaria, Namutumba District, Eastern Uganda, September 2021 – February 2022

Background: In February 2022, a high number of deaths among children was reported to the Ministry of Health from Namutumba District. The cause was later confirmed as severe malaria. We investigated the scope of severe malaria deaths, identified associated factors, and recommended evidence-based control measures to inform malaria-prevention programming in Namutumba Distric

Methods: We conducted an unmatched case-control study in March 2022 in the most affected subcounty (Ivukula Subcounty). We defined a case as death with a history of fever and any of the following: convulsions, difficulty breathing, yellow eyes, tea-colored urine, anemia, loss of consciousness, or reduced urine output in a child ≤12 years from September 2021 to February 2022 in Ivukula Subcounty, Namutumba District. Controls were survivors with the same signs and symptoms, recruited in a 2:1 ratio with cases. We actively searched for cases and controls door-to-door with the help of community health workers. We interviewed caretakers for cases and controls to obtain socio-demographic and clinical data, including health-seeking behavior and health systems risk factors. Drugs and bloodstock status information was obtained from health workers using an interview guide. We identified factors associated with death using multivariate logistic regression and thematic analysis for qualitative data.

Results: Among 46 cases, 29 (63%) were <5 years, and 23 (50%) were female. Death among children with severe malaria was significantly associated with treatment non-completion (aOR=9.7, 95%CI: 1.8–53) and failure to receive blood transfusion for anemic patients (aOR=7.1, (95%CI: 1.4–36). Healthcare workers reported that failure to reach intended referral sites due to transport costs, stockouts of antimalarials and blood products at health facilities, and absence of integrated community case management of childhood illnesses (iCCM) were likely contributors to deaths among children with severe malaria.

Conclusion: Incomplete or insufficient treatment due to lack of patient resources and drug stockouts contributed to malaria mortality among children ≤12 years in Ivukula Subcounty in Uganda. We recommend accurate quantification of antimalarials for health facilities, offering transport support to severe patients referred to higher-level facilities, and increasing access to blood products. Activation of iCCM could facilitate public health efforts against severe malaria in the district.

Key lessons learnt during the fellowship

• Outbreak detection, response and control
• Project designing and proposal writing
• Grant writing
• Designing and implementation of quality improvement projects
• Scientific writing (abstracts, manuscripts, policy briefs)
• Newspaper article writing
• Scientific reviewing
• Editorial Skills
• Data analysis using Epi-info, STATA, QGIS and interpretation of results
• Public speaking
• Scientific communication
• Mentorship and training

Next Steps

• Finalize and publish all research manuscripts drafted during the fellowship and engage further in global health security interventions and research
• Furthermore, I intend to continue supporting the field epidemiology training program whenever called upon.

Pictorial