6.1. Very high malaria transmission intensity
Uganda has some of the highest recorded measures of malaria transmission intensity in the world. In this setting malaria elimination is not a realistic short- or medium-term goal, and even advances in control are challenging. Lessons from regions in which elimination efforts have already been successful may be of little relevance for Uganda. In highly endemic areas, profound decreases in transmission will likely be required to impact significantly upon the incidence of disease. If such advances are achieved, they may be accompanied, as in areas of Uganda with lower transmission intensity, by epidemic disease, as populations with diminished antimalarial immunity are periodically beset by transmission of infections that are increasingly likely to cause severe disease. Key features of the Uganda vector control strategy are distribution of ITNs and utilization of IRS. The roll out of ITNs has been fairly successful in recent years, but only about a third of children and pregnant women reported sleeping under a net on the night prior to the UMIS (Uganda Bureau of Statistics, 2010
). Some targeted IRS has been carried out, but implementation has been irregular, with interruptions in spraying activities and limited geographic coverage. Poor communication on the IRS strategy and the safe use of DDT has caused misperceptions about this strategy within communities and other interest groups. In addition, resistance to insecticides may compromise the overall vector control program. Importantly, there remains uncertainty about the advisability of IRS in high transmission areas and so, while the strategy is validated for some areas, and successes have been seen in Southwestern Uganda, the appropriate role of IRS for most of the country is uncertain. More broadly, a full integrated vector management system, including evidence-based decision-making; integrated approaches; collaboration within the health sector and with other sectors; advocacy, social mobilization, and legislation; and capacity-building is not yet in place (Beier et al., 2008
6.2. Inadequate health care resources
All public health is seriously compromised in Uganda, and throughout sub-Saharan Africa, by limited resources. Considering malaria, this situation has improved somewhat in recent years, with significant increases in international investment in malaria control and elimination. However, resources remain very inadequate, and there is fear that they will decrease. This decrease may be driven by global economic circumstances, donor fatigue, and also misplaced appreciation of the new malaria elimination agenda. This agenda may drive increased investment in malaria, but it may falsely impress donors that control is of decreasing importance. It is very important that, as enthusiasm for elimination in other areas increasingly gains attention, interest in strategies for control in areas with persistent high transmission intensity and malarial incidence, such as Uganda, is not lost.
6.3. Weaknesses in the health system
The Ugandan healthcare system is seriously compromised by limitations in resources, governance, and accountability. While there are many different partners, working groups, and committees, the malaria community remains quite fragmented. There remains poor coordination of malaria partners and interventions, and engagement among groups is irregular. Weaknesses and gaps in this system include poor coverage of lower-level health centers and village health teams, lack of effective supervision, high attrition of staff at health centers, irregular availability of drugs and other supplies, and poor coordination and leadership.
6.4. Inadequate understanding of malaria epidemiology and of the impact and optimal use of interventions
A major challenge to malaria control is our lack of a detailed understanding of the epidemiology of malaria in Uganda and of the impact of available control interventions. The epidemiologic data described throughout this paper are, for the most part, estimates based on inadequate information. More detailed surveillance is needed to better characterize the malaria situation. Of perhaps even greater importance is the determination of the impact of control interventions. Indeed, although the potential value of various interventions is clear, it is difficult to determine whether utilization of ITNs, IRS, treatment with ACTs, or targeted use of IPT has yet importantly impacted on malarial morbidity and mortality in Uganda. Further, with identification of optimal control interventions, operations research addressing how to scale up interventions to maximize effectiveness and cost-effectiveness, and how to prioritize combinations of interventions and effectively target high-risk groups, is essential. Critical for assessing the effectiveness of malaria control activities is the ability to measure and monitor the quantitative impact of interventions on malaria-associated morbidity and mortality. Ideally, accurate data on malaria-associated morbidity should be linked to implementation projects in order to evaluate their impact. Practical and sustainable programs are needed in order to provide baseline surveillance statistics and to measure impact following implementation of control activities. Monitoring and evaluation to measure progress against project goals and targets, to inform policy-making processes, and to facilitate adjustments in implementation is a critical requirement of effective health care management and delivery. Considering the knowledge gaps described above, the institution of an integrated and in depth research program on malaria epidemiology and vector dynamics in Uganda would be an important advance.
6.5. Increasing resistance of parasites to drugs and of mosquitoes to insecticides
As described above, malaria control is challenged both by resistance of P. falciparum
to available drugs and of anopheline mosquitoes to available insecticides. Regarding drugs, we are fortunate that resistance to artemisinin-based drugs does not yet appear to be a problem in Uganda (Nsobya et al., 2010
). However, resistance to long-acting partner drugs utilized in ACTs is concerning, both in regard to drugs that already suffer from resistance (amodiaquine) and those for which resistance may be selected (lumefantrine, dihydroartemisinin). Resistance also jeaopardizes continued efficacy of antifolates to prevent malaria in IPT regimens, as will be discussed below. Regarding insecticides, resistance to the two main classes of insecticides utilized in Uganda, DDT and pyrethroids, is of great concern, in particular because only pyrethroids are available for ITNs. However, the extent of resistance, especially to insecticides, is not well described for much of the country.
6.6. Inappropriate case management
The new national case management strategy is to confirm all suspected cases of malaria and treat confirmed cases with ACTs, while referring or managing those without malaria for other possible causes of fever. Major weaknesses currently hindering effective malaria case management are delays in seeking treatment, lack of diagnostic tests, and lack of access to ACTs. A major challenge has been the slow transition of health worker practices from presumptive to confirmed malaria case management. This problem has been exacerbated by a lack of laboratory diagnostic capacity in many health facilities. Even in those facilities with malaria microscopy, many clinicians lack confidence in the results and may disregard them when making a diagnosis. Laboratory diagnostic capacity for malaria (by microscopy and, to a much smaller extent, rapid diagnostic tests) exists in only 26% of all health facilities (Uganda Ministry of Health, 2008
). The 2009 UMIS indicated that only 17% of children treated for malaria had a diagnostic test done (Uganda Bureau of Statistics, 2010
). With these limitations, presumptive treatment of all suspected malaria cases without a diagnostic test remains common in Uganda. The 2009 UMIS also showed that there remain significant delays in seeking treatment for malaria and in accessing ACTs. Only 36% of febrile children received an antimalarial within 24 hours. Furthermore, although 23% of febrile children received ACTs, only 14% did so within 24 hours of the onset of fever .
6.7. Inadequate utilization of drugs in malaria prevention
The only established program to use drugs in control is IPTp, but utilization remains inadequate. Although the IPTp policy has been in place for more than ten years, and despite good antenatal clinic attendance, according to the 2009 UMIS only 33% of pregnant women received the minimum recommended two doses of SP. Further, the efficacy of IPTp in Uganda is likely seriously jeopardized by resistance of P. falciparum
to SP. In contrast to pregnant women, WHO recommendations do not support use of IPT in Ugandan infants due to the prevalence of resistant parasites in the country. Replacements for SP for IPT are of great interest, but no other regimen is validated for this purpose, and use of long-acting ACTs, which will likely offer the best clearance of parasites, is discouraged by many authorities due to potential selection of drug resistance. The effectiveness of IPT for older children, including programs directed at schoolchildren, has not been evaluated in detail in Uganda, but it is noteworthy that a single dose of SP offered no benefit over placebo in preventing infections in schoolchildren in eastern Uganda (Nankabirwa et al., 2010
6.8. Inadequate epidemic preparedness and response
Epidemic malaria transmission occurs in approximately 15 districts in the southwest and eastern highland regions of Uganda. National recommendations and guidelines for epidemic preparedness are in place for early detection and rapid containment of malaria epidemics. Epidemic thresholds are established for each district based on past data. The Epidemic Surveillance Department of the MOH provides weekly updates on cases of epidemic-prone diseases, including malaria. However, case reporting is inadequate, and districts are often unable to implement epidemic control recommendations due to limitations in resources and availability of supplies, including diagnostics and drugs.