Malaria in Uganda: challenges to control on the long road to elimination: I. Epidemiology and current control efforts

Abstract

Malaria remains one of the leading health problems of the developing world, and Uganda bears a particularly large burden from the disease. Our understanding is limited by a lack of reliable data, but it is clear that the prevalence of malaria infection, incidence of disease, and mortality from severe malaria all remain very high. Uganda has made progress in implementing key malaria control measures, in particular distribution of insecticide-impregnated bednets, indoor residual spraying of insecticides, utilization of artemisinin-based combination therapy to treat uncomplicated malaria, and provision of intermittent preventive therapy for pregnant women. However, despite enthusiasm regarding the potential for the elimination of malaria in other areas, there is no convincing evidence that the burden of malaria has decreased in Uganda in recent years. Major challenges to malaria control in Uganda include very high malaria transmission intensity, inadequate health care resources, a weak health system, inadequate understanding of malaria epidemiology and the impact of control interventions, increasing resistance of parasites to drugs and of mosquitoes to insecticides, inappropriate case management, inadequate utilization of drugs to prevent malaria, and inadequate epidemic preparedness and response. Despite these challenges, prospects for the control of malaria have improved, and with attention to underlying challenges, progress toward the control of malaria in Uganda can be expected.

Figure 1. Malaria endemicity in Uganda

Values are estimated based on available data, which are limited for many regions of the country. Parasite prevalence estimates are for children under 10 years of age. EIR, entomological inoculation rate.

Figure 2. Malaria parasite prevalence in Ugandan children under 5 years of age in 2009

Data are from the 2009 Uganda Malaria Indicator Survey (Uganda Bureau of Statistics, 2010).

Figure 3. Reported malaria cases in Uganda: 1997–2009

Total cases reported to the Uganda Health Management Information System are shown, including crude numbers (blue), those adjusted based on an estimate of episodes missed due to absent reports from health facilities (yellow), and estimates of cases confirmed by diagnostic tests, based on smear positivity rates determined from the 2009 Uganda Malaria Indicator Survey (Uganda Bureau of Statistics, 2010; red). Cases for 2009 are projected for the full year based on data from January-June.

Figure 4. Smear positivity rates for children under 5 years of age at 6 health centers representing regions of very high (Apac, Tororo), moderate (Jinja, Mubende), and relatively low (Kanungu, Kabale) malaria transmission intensity

Graphs show the proportion of diagnostic tests that were positive for children suspected of having malaria at each site. The diagnostic test was usually microscopy, but an HRP2-based rapid diagnostic test was used in some cases.