Fewer malaria cases but death toll still high

For 25-year-old Derrick, life means nothing without fish risking his life daily to get a catch is the definition of life. The more the fish, the better life would be. But, not everything was rosy.

His fishing nets became old with time and needed to be replaced. He says the scarcity of good long-lasting nets made it hard for him to buy one until a solution presented itself when government started distributing mosquito nets countrywide. Derrick says because the nets have smaller spacing, they are efficient with fishing.

“All I had to do was get as many nets as possible and since I have many family members, I managed to procure five nets which I have been using and my income has increased greatly” he asserts.

Derrick’s situation is no different from that of people who knowingly refuse to consistently take their malaria medication or sleep under treated mosquito nets.

According to Dr Peter Albert Okui, the programme manager of National malaria control programme (NMCP), malaria is still one of the leading problems in the country causing high morbidity and mortality rates.

According to the recently published Uganda Malaria Indicator Survey (UMIS) 20142015, there is a decline in the general malaria prevalence in the country from 49 per cent in 2009 to 19 per cent.

The decline in number of malaria cases could be attributed to government interventions together with support from development partners, including the United States Agency for International Development (Usaid) and the United Kingdom Department for International Development (DFID) and Global Fund (GAVI) who provide financial and technical support.

Mosquito nets
When a mosquito net is treated with the right insecticide, there is a certain amount of protectiveness that is achieved.

Dr Peter Albert Okui, the programme manager of National Malaria Control Programme (NMCP) says nets have been found to be 50 per cent effective in fighting malaria. However, he warns that sleeping under one, is a lifetime activity.

Results from the malaria indicator survey (UMIS) show that the percentage of households with at least one mosquito net has increased from 60 per cent in 2011 to 90 per cent and usage has also increased from 43 per cent in 2011 to 74 per cent. Usage in pregnant women was also found to have increased from 47 per cent to 75 per cent.

Use of antimalarial drugs
In the efforts to reduce malaria incidence, drugs are a vital part. Dr Okui says malaria drugs are now more available in hospitals with recent data from UMIS showing that 87 per cent of those found positive were able to receive the necessary drugs.

The survey showed that there is a 15 per cent increase in the number of pregnant women who take fansidar during their pregnancy from 25 per cent to 45 per cent.
“When a mother is pregnant, the parasite can evade the placenta effectively and affect both mother and baby, causing damage.

It can cause conditions such as anaemia and low birth weight if not treated,” Dr Okui explains. He attributed the low coverage to the poor attitude of mothers towards medicines but was quick to add that further studies are going on to tackle the problem.

He cites pregnant women and children under the age of five as the most vulnerable groups of people who are prone to infection and subsequently death as a result of malaria. Information from the Ministry of Health indicates that 60 per cent of the miscarriages suffered are as a result of malaria.

“When still in the womb, children tend to share their mother’s immunity and after birth, they can retain that immunity for up to two months. After that, the immunity wears off and becomes low making them prone to getting severe malaria.
Because of their infant age, diagnosis is also hard and there can be delays,” Dr Okui explains.

He adds that in addition, medicines for the treatment of malaria do not cater for children because they are mostly meant for adults which risks under or overdosage, especially in the case of tablets.

Why death toll is still high
Malaria still remains one of the leading causes of death accounting for between 10,000 to 15,000 deaths every year. In comparison, six per cent of the national deaths are attributed to cancer accounting for approximately 20,000 deaths per year, World Health Organisation says while there are about 63,000 HIV related deaths annually according to UNAIDS.

Dr Myers Lugemwa, the director of the National Malaria Control Programme says we should not expect malaria incidence to reduce all of a sudden because the prevalence has reduced. He gave an example of a mosquito which can kill 100 people and even though the number reduces to 50, the deaths still remain high.

“Malaria has been the leading cause of death in the country for a long time as opposed to other diseases. Even though the numbers of deaths affiliated to it reduce, the prevalence will still remain relatively higher. You do not control mosquitoes and we should still be worried,” he says.

He also cited the inability to implement strategies aimed at combating malaria at the same time as one of the reasons as to why there is still a high incidence.

Dr Charles Lwanga Sezi, a retired senior consultant physician says the high incidence and death of malaria can be attributed to the fact that there are still very many people who already have the malaria parasites still living in them.

“The 2009 survey showed that over 80 per cent of the children under five in the northern region had malaria parasites. In young people, this figure is still high which means there are more people with malaria. As a result, transmission is inevitable,” he explains.

Dr Okui attributes the high incidence to the humid climate which favours the multiplication of the mosquitoes making it easy for them to transmit the parasite from person to person.

Dr Sezi adds that malaria will not be fully controlled if attention is still paid to the mosquito instead of the parasite within the humans. He adds that the approach to malaria control should be changed from simply killing the mosquito to taking care of the parasite by massive drug administration.

“What we need is to rid our bodies of the malaria parasites through the administering of drugs. If the malaria parasite does not exist in our bodies, there will be no malaria.

If only every Ugandan would be able to receive the drugs at the same time, we would have wiped out malaria, we need multi-drug administering for better results,” Dr Sezi suggests.

However, the country may be moving closer to mass action against malaria, with the ongoing trials for a malaria vaccine.

Controlling malaria with residual spray

The Ministry of Health in 2008 embarked on Indoor Residual Spraying (IRS) in the districts with the highest malaria prevalence. Ten districts in northern Uganda were first targeted. Among the beneficiaries were Kole, Oyam and Apac districts.

At the time of spraying, eight out of 10 people would have malaria parasites in their blood if tested.

According to Center for Disease Control (CDC) website, IRS is one of the most effective ways of preventing the transmission of the malaria parasite from one person to another. Malaria consortium website states that ‘generally all internal walls and ceilings of the building are treated.’

Due to the spraying, surveys show that there has been a huge decline in the malaria prevalence rates in the areas sprayed from 63 per cent to 20 per cent. Because of the high success rates, the exercise has been extended to more 14 districts including Bugiri, Namutumba, Lira, among others.

IRS is a standardised and well-established control method for mosquitoes. It has been used widely in Asia, the Pacific and Latin America, while in Africa its use has been more limited to the margins of malaria distribution in southern Africa and to epidemic-prone countries often at higher altitudes. WHO has recently proposed extending its range in Africa.

IRS can kill a mosquito any time it enters a house for a blood meal, which it typically does every two to three days, so that few will survive the approximately 12 days that are required for malaria parasites to complete part of their life cycle in the vector mosquito, if all the houses they visit are properly sprayed.

In practice, the effectiveness of IRS depends on adherence to application procedure, efficacy of the insecticide, public acceptance of spraying, availability of well-maintained equipment, adequately trained spraying personnel, efficient supervision and strong financial support.

The size of the operational area depends on local circumstances and is influenced by the distribution of malaria and malaria vectors, the distance from important breeding sites, the flight range of the vectors and demographic features.

Generally, all internal walls and ceilings of the building are treated. Residual effects depend on porosity of the surface (shorter on mud walls) and exposure to sunlight.

Four classes of chemical insecticides-organochlorines, organophosphates, carbamates and pyrethroids-are still the mainstay of vector control programmes.
Use of pyrethroid insecticides has, however, increased, and that of the organochlorines and some of the more toxic organophosphate compounds has decreased in recent years.

The continued use of DDT for disease vector control is conditionally approved under the Stockholm Convention on Persistent Organic Pollutants, in accordance with WHO recommendations and guidelines, and when locally safe, effective and affordable alternatives are not available.

Efforts to reduce death from malaria

The newly released Uganda Malaria Indicator Survey 2014-15 (UMIS) indicates that the national malaria prevalence has declined to 19 per cent from 42 per cent in 2009.

Although malaria remains one of the leading causes of death, the number of deaths registered daily has reduced from about 320 to less than 100 deaths currently.

The interventions include: scaling up the treatment services, indoor residual spraying (IRS) of insecticides and large-scale use of the long lasting insecticide treated nets (LLINs).

The 201415 National budget prioritised the implementation of the Malaria strategy for effective control through mass distribution of Long lasting Insecticide Treated Nets (LLINs) and mass indoor Residual spraying (IRS) starting in high malaria prone areas of Lake Kyoga and Northern Uganda. In 2014, about 21 million mosquito nets were distributed.
Five per cent of Ugandan homes had their interior walls sprayed in the six months before the survey whereas 44 per cent of homes were sprayed using IRS in the mid north. Currently, 90 percent of the households in Uganda own at least one mosquito net compared to 47 percent in 2009. Forty five per cent of pregnant women took 2+ doses of SPFansidar, at least once during an antenatal visit as opposed to from 32 per cent in 2009.

Government is currently conducting trials on a malaria vaccine in Iganga Distict with hopes of introducing it in the future.

Additional information from malariaconsortium.org

editorial@ug.nationmedia.com

SOURCE: Daily Monitor

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