Malaria- Battling Country's Big Killer

Irene Nabusoba | 14 Feb 2010
New Vision
Kampala — A mother gets her child tested for malaria. Doctors advise that quinine be given intravenously.

The months of November, December and January saw malaria rise to epidemic levels because of prolonged rains. As a result, the national transfusion services even ran out of blood because of overwhelming cases of malaria-related anaemia.

The blood bank recently embarked on donation campaigns, announcing that it now has a sufficient stock. However, that is just part of the problem solved.

Medical experts warn that other complications like miscarriages, cerebral palsy, and Burkitt's lymphoma (a cancer in children caused by poor hygiene and malaria) remain.

"The rains have subsided but the malaria epidemic is far from over," says Dr. Richard Ndyomugyeni, the director malaria control programme in the Ministry of Health. "We have a lot of stagnant water that provides a conducive environment for mosquitoes to reproduce."

Access to treatment

Global research shows that nearly a million people die from malaria each year because they cannot afford the most effective treatment - Artemisinin combination therapy (ACT) recommended by the World Health Organisation.

According to a study, 'ACT Watch' by PSI and the London School of Hygiene and Tropical Medicine on the malaria drugs market, many countries changed their treatment policies to favour ACT drugs in the face of widespread resistance to older medicines.

It adds that ACT availability is as low as 20% in public health clinics while ACTs make up only five to 15% of the total volume of anti-malarials on the market.

The picture is not any different locally.

The Government switched to ACTs, popularly known as coartem, as the first-line treatment of malaria, but they are expensive, with a dose costing between sh15,000 and sh25,000.

Desmond Chavasse, the PSI director says: "A full course of ACT for an adult can be up to 65 times the minimum daily wage. This forces patients to make the wrong anti-malarial choice."

Yet Ndyomugyenyi advises patients to take coartem and adhere to their doses to avoid malaria cases leading to anaemia. He says ACTs are recommended for complicated malaria, while quinine is for severe malaria.

"But we are moving away from quinine because of the associated complications from poor training of lower level health workers to administer it through injections. When not mixed in the right proportions, quinine can be deadly.

"Nevertheless, quinine is not the best drug because compliance is difficult. We prefer artesunate or artementer injections," Ndyomugyenyi says.

He adds: "We resort back to quinine even against health policies because of stock-outs. It is a big problem because of overdependence on donors, especially the Global Fund."

Ndyomugyenyi says since 2007, they have not received coartem and funds are still lacking. He says the Government committed sh60b for HIV and ACTs last year, but calls for increased investment in malaria programmes.

Answer is in prevention

Malaria is endemic in most of Uganda, but basic preventive gear like bed nets is beyond the reach of many. Nets upcountry cost sh6,000, which is not affordable by many people.

The Government is emphasising preventive measures like indoor spraying and use of treated mosquito nets.

Dr. John Rwakimari of the National Malaria Control Programme says malaria prevalence rates are down because of increases in net coverage. "We had the highest malaria rates in 2005 (16 million cases). We noted a 40% reduction to about 10 million cases in 2007 because of mosquito nets, ACTs and indoor spraying. In 2004, we had 10% coverage of nets but we are now at 42%."

Ndyomugyenyi says they have distributed seven million nets so far. "At the end of this month, we shall receive 2.8 million nets more and another 7.2 million at the end of May which we should have distributed by December."

He notes that distributing nets is not enough. People must use them if malaria is to be curbed. "Please sleep under a net. When given drugs, complete the dose to minimise resistance which complicates the condition," Ndyomugyenti says.

He adds that Uganda also needs full coverage of indoor residual spraying especially in areas of high transmission.

"We have done well in Kitgum and Apac. In February, we intend to cover six districts in the central region," Ndyomugyenyi adds.

He advises people to embrace spraying. "When officials come to spray in your home, please let them. People have mistaken indoor residual spraying to be synonymous with DDT. We use a different, safe chemical."

Burden of malaria

Malaria is the leading cause of death in Uganda killing 70,000 to 110,000 people per year, that is 320 people everyday, mostly pregnant women and children below five years.

It is endemic in 95% of the country,

nIt forms 30-50% of the outpatient department attendance, 20% of in-patient admissions, and 9-14% of the deaths of admitted cases.

About 25% of household income is spent treating malaria

$6m (sh12b) is lost annually in terms of productivity.

Diagnosis challenges

Health workers say there is a growing concern of diagnoses giving false results.

"The test shows no malaria when every sign points to it. After two days, the malaria shows. Ignorant mothers may leave their children to fate only to breath their last," says Maimuna Ziraba, a midwife operating a private clinic.

But Dr. Ambrose Talisuna, the country representative, Medicines for Malaria Ventures, observes that not all fever is due to malaria.

"We need to improve on our diagnosis techniques to avoid treating blindly," he says. "Health workers should consider other infections and provide appropriate medication to decrease mortality."

Talisuna argues that some of the tests are not 100% correct. Some may show negative and later turn positive or show positive even when the parasites have cleared.

He says if the blood slide is negative, try testing for something else like pneumonia, ear infection or other infections.

"Traditionally, we use microscopes but we have lately introduced the rapid diagnostic test. We plan to use even at community level, once we have sufficient stocks of ACTs so that every case is treated immediately," Talisuna concludes.