Malaria remains the number one cause of morbidity and mortality in Uganda (Republic of Uganda MoH, 2017). In 2009, the United States’ President’s Malaria Initiative (PMI) supported the implementation of an IRS programme in 10 districts in northern Uganda with high levels of malaria transmission intensity, including Nwoya District. The programme achieved coverage levels consistently above 95% and resulted in marked reductions in the malaria burden, and a prevalence of just 7 percent (Raouf et al, 2017). The IRS programme was suspended in the 10 northern districts in 2014, with hopes that the gains achieved would be sustained following a universal coverage campaign (UCC) with long lasting insecticidal nets (LLINs). Unfortunately, although planned to coincide with the UCC, the discontinuation of IRS began before the LLIN distribution was completed (Republic of Uganda MoH & WHO 2016). Existing interventions were not sufficient to maintain the reduced malaria transmission intensity which was achieved with IRS. The ecosystem regained its receptivity to malaria transmission and the years immediately following the withdrawal of IRS in northern Uganda saw malaria prevalence among children increase dramatically, from 34 percent in 2014 to 63 percent in 2016 (Republic of Uganda MOH NMCP & WHO 2016).
The National Malaria Control Programme (NMCP) and partners provided technical assistance to the affected districts, health facilities (HFs), and communities. These activities were conducted in a targeted manner according to the identified gaps and need. The 2016 upsurge led to an increased focus on training district malaria program staff on malaria surveillance, epidemic preparedness, and response. A three-stage comprehensive response plan was developed for the affected districts, among which a key intervention was to set up district malaria response teams.
Since the withdrawal of IRS and subsequent 2016 malaria upsurge, Nwoya District has continued to experience periodic malaria upsurges (Republic of Uganda MoH, 2017). In 2018 between weeks 41 and 43, an increase was observed in reported malaria cases by 1,332 cases. This was based on data submitted weekly from health workers through mTRAC into the District’s Health Information System (DHIS) (Figure 1 below). Unlike with the 2016 upsurge, which was brought to the attention of the Ministry of Health (MoH) by the Ugandan press, the strengthened surveillance and response capabilities enabled the DHT to rapidly, and successfully, detect (and respond to) the upsurge.
Literature review
The concept of surveillance and response evolved from the original vision of the general and open-ended-term ‘surveillance’, defined as “the continuous and systematic collection, analysis and interpretation of disease-specific data, and the use of that data in the planning, implementation, and evaluation of public health practice” (The malERA Consultative Group on Monitoring, Evaluation, and Surveillance, 2011, WHO 2006). Timely dissemination of surveillance results can improve planning, implementation, and evaluation of interventions (Zhou et al 2013).
Surveillance is therefore the basis of operational activities in settings of any level of transmission. Its objective is to support reduction of the burden of malaria, eliminate the disease and prevent its re-establishment (WHO 2018). In high transmission settings, malaria surveillance data is used to monitor trends in the number of cases and deaths, over time and by geography; the characteristics of people infected or dying from malaria; and the seasonality of transmission. In such settings, surveillance data can also be used to stratify geographical units by their malaria prevalence or annual parasite incidence, to better target interventions and optimize resource allocation (WHO 2019). By strengthening capacity to assess trends and respond without delay, surveillance itself can become an intervention (Zhou et al 2017). Surveillance is the third pillar in the World Health Organization (WHO) Global Technical Strategy for Malaria and is earmarked as a key intervention for malaria control, including improved monitoring and evaluation as well as stratification of geographical areas by burden (WHO 2015). The Global Malaria Program (GMP) has embarked on an intensified process of improving national surveillance systems and the use of data for programmatic decision-making (WHO 2019). Surveillance systems should be robust enough to detect and respond to malaria upsurges within two weeks of onset. To be truly effective, strong national surveillance systems with malaria upsurge early warning triggers, need to be linked to efficient and high quality, localised surveillance systems (The malERA Consultative Group on Monitoring, Evaluation, and Surveillance, 2011).
Surveillance and response systems provide an early warning function and serve to provide data that can be used to detect and respond to outbreaks or public health threats, such as malaria upsurges, in a timely and appropriate manner (WHO 2006). The strength of such systems should be judged based on:
- Early detection of case load by the system
- Epidemiological investigation undertaken.
- Timely initiation of response and
- use of the surveillance data to guide the public health response
Objective
Based on lessons learnt from a district-led intervention in Northern Uganda, this case study demonstrates that malaria surveillance and response, with precisely targeted multipronged activities, is an effective and efficient approach to managing malaria upsurges[1] following the withdrawal of IRS programmes. The outcome of such a district-led response to an upsurge in Nwoya District led to a significant reduction in routinely reported malaria cases from an average of 2513 cases per week to 1335 cases per week, between week 43 of 2018 and week 10 of 2019. [2]