Rebecca Bauer
Malaria in Uganda
From: Secretary of Health, Uganda
To: Minister of Finance, Uganda
Introduction
Malaria is the leading cause of morbidity in Uganda and is responsible for up to 40% of all outpatient visits, 25% of all hospital admissions, and 14% of all hospital deaths.1 Currently, 95% of our population is at risk,1 and malaria kills between 70,000 and 100,000 children every year.2 Uganda's high rates of malaria disproportionately affect young children and pregnant women in rural areas who experience extreme poverty, limited access to healthcare services, and lack of education.3Malaria has negative health and economic effects, and restricts the productivity of our population. Increased Insecticide Treated Bed Net (ITN) coverage and education, improved access to and delivery of treatment, and emergency control of malaria are essential to control malaria in Uganda.
Nature and Magnitude of the Problem
Malaria is the leading cause of morbidity and mortality in Uganda.1 Our country has the world's highest malaria incidence, with a rate of 478 cases per 1000 population per year.4 Uganda has the third largest malaria burden in Africa and the sixth largest in the world.5 Currently, 95% of our population is at a highly endemic risk, and the remaining 5% of the country is prone to malaria epidemics.6 Malaria is responsible for up to 40% of all outpatient visits, 25% of all hospital admissions, and 14% of all hospital deaths.1 An estimated 12 million clinical cases are treated annually in the public health system alone.7
Child deaths due to malaria are between 70,000 and 100,000 every year, a death toll that far exceeds that of HIV/AIDS.2 Additionally, malaria affects maternal morbidity and mortality and is attributed as a direct or indirect cause of 65% of maternal mortality and 60% of spontaneous abortion. Additionally, 15% of life years lost to premature death are due to malaria and families spend 25% of their income on this disease.1
Affected Populations
Children under the age of five and pregnant mothers living in rural areas are disproportionately affected by malaria.8 Rural inhabitants contribute to 87% of the burden of disease,8and nearly half of all inpatient deaths among children under-five years of age are attributed to malaria.9Pregnant women have a greater risk of developing severe disease due to a malaria infection than are non-pregnant adults living in the same area. The increased risk of malaria during pregnancy is due to malaria-related anemia.10 Populations living in rural areas have a higher rate of incidence of malaria but receive less treatment than those living in urban areas.
Risk Factors
Age and pregnancy status are among the highest risk factors for contracting malaria. Additional risk factors are proximity of households to rice-growing areas, extensive poverty in rural areas, lack of knowledge on how to prevent and treat malaria, and little to no healthcare access.3 Transmission of malaria occurs year round in most parts of Uganda,8and our climate and heavy rainfall greatly contribute to malaria transmission in 90 to 95% of the country.3 Rural inhabitants have a much higher risk of malaria transmission and in some districts receive more than 1,500 infectious bites per year.3
Malaria transmission is significantly reduced by the use of Insecticide Treated Nets (ITN's); however, only 10% of children under five years and pregnant women sleep under ITN's.11Further, only 12.8% of the country as a whole use ITN's and only 34% use basic mosquito nets;3however, this rate is greatly reduced in rural areas where prevalence is highest. The use of ITNs by children in urban areas far outnumbers the rates in rural areas, despite the higher incidence of malaria.8
Ugandans are at risk for all four human Plasmodia species, with P. falciparum being the most common and responsible for 90 to 98% of diagnosed cases and almost all cases of severe malaria.3The most common malaria vectors in Uganda are theAnopheles gambiae s.l. and theA. Funestus and without the use of ITN's and Indoor Residual Spraying (IRS), the population remains at high risk.3Additionally, due to the widespread use of sub-standard or counterfeit drugs, resistance to anti-malarial drugs is an increasing problem, and those without proper care risk drug resistance.3
Economic and Social Consequences
Malaria poses a significant risk to our country’s overall health and economy. Malaria has negative economic effects for the national economy due to lack of production, and at the household level causes an immense burden, particularly for the poorest households, by reducing the number of days a patient can work by seven per episode and additional costs relating to care.3 Malaria-related expenses account for 34% of total expenditure for the poorest sections of the country.3 This also creates a heavy burden upon the health system, with malaria accounting for up to 40% of all outpatient visits, 25% of all hospital admissions, and 14% of all hospital deaths.1
Malaria infections received by pregnant women result in adverse pregnancy outcomes, including spontaneous abortion, neonatal death, and low birth weight, and is estimated to cause as many as 10,000 maternal deaths each year, 8% to 14% of all low birth weight babies, and 3% to 8% of all infant deaths.10 Other malaria related complications during pregnancy lead to reduced neurocognitive function in the child, which can lower educational attainment, depress literacy rates, and damage long-term health and labor productivity,12 which further affects our economic growth.
Priority Action Steps
The control over malaria in Uganda is dependent on prompt diagnosis and treatment, as well as the implementation of preventative measures. The use of Insecticide Treated Nets (ITNs) and Long-Lasting Insecticide Nets (LLINs), Indoor Residual Spraying (IRS), and Intermittent Preventive Treatment (IPT) of pregnant women will address this issue and lower our high rates of malaria. Additionally, education regarding the importance of sleeping under Insecticide Treated Nets and other methods of prevention must be addressed.
Additionally, we must introduce health systems which ensure the increased coverage of first-line and effective Artemisinin Combination Therapy (ACT) treatments of malaria, as well as perform case management to ensure early diagnosis and that medications are used efficiently. These steps will result in healthier outcomes for Uganda and improve the productivity of our population.
Bibliography
1Uganda Ministry of Health (unpublished).
2Lynch KI, Beach R, Asamoa K, Adeya G, Nambooze J and Janowsky E. President's Malaria Initiative, Rapid Assessment Report - Uganda, 2005
3Department for International Development. Where we work: Uganda-Key Facts. 2011.
4Organization WH. World Malaria Report, 2005. Geneva, Switzerland: World Health Organization, 2006.
5Malaria Consortium. “Malaria Consortium in Uganda”. 2011.
6 Miriam Nanyunja, Juliet Nabyonga Orem, Frederick Kato, Mugagga Kaggwa, Charles Katureebe, and Joaquim Saweka, “Malaria Treatment Policy Change and Implementation: The Case of Uganda,” Malaria Research and Treatment, vol. 2011, Article ID 683167, 14 pages, 2011. doi:10.4061/2011/683167
7Pullan et al.: Plasmodium infection and its risk factors in eastern Uganda. Malaria Journal 2010 9:2.
8The World Health Organization. “World Malaria Report 2010: Uganda”.
9President's Malaria Initiative. Country Profile. President's Malaria Initiative (PMI): Uganda. April 2011.
10Roll Back Malaria. 2001-2010 United Nations Decade to Roll Back Malaria. Malaria in Pregnancy.
11UNICEF. United Nations. Economic and Social Council. 13 July 2009. United Nations Children's Fund: Uganda.
12 Barofsky, J,. Chase, C., Anekwe, T., Farzadfar, F. Harvard Initiative for Global Health. The economic effects of malaria eradication: Evidence from an intervention in Uganda. May 2011.