DOI: https://doi.org/10.21203/rs.3.rs-52816/v1
Background
Malaria remains the number one cause of morbidity and mortality in Uganda. In 2009, an indoor residual spraying (IRS) programme was implemented in 10 Northern districts, resulting in marked reductions in the malaria burden, and a prevalence of just 7 percent. IRS was withdrawn after five years and malaria prevalence among children subsequently increased dramatically from 2014-2016. This upsurge led to an increased focus on training district malaria programme staff on malaria surveillance, epidemic preparedness, and response. An increase in malaria cases was detected again in 2018 in Nwoya district.
Methods
In response to the increase in malaria cases, the District Health Team (DHT) set up multi-sectoral management taskforce and technical rapid response team (RRT). The RRT was responsible for a rapid assessment, mapping exercises and identifying possible causes. The DHT informed all relevant stakeholders of the findings, mobilised resources and developed a comprehensive response plan. Interventions were categorised as immediate (to treat cases and avert deaths), intermediate (to bring down the epidemic) and long-term (to sustain the gains achieved). Health workers from the affected areas were trained on integrated management of malaria, village health team (VHT) members were mentored on malaria epidemic response and their role in the response plan, and health facilities conducted test, treat and track outreach activities. Social behaviour change and communication (SBCC) played a key role, and the RRT monitored and ensured that there were enough malaria commodities at the facilities and for the VHTs.
Results
The Nwoya DHT was able to detect the 2018 upsurge from the district records, raise awareness, and respond effectively in a timely manner. This district-led response led to a reduction in routinely reported malaria cases from an average of 2,513 cases per week to 1,335 cases between week 43 in 2018 and week 10 in 2019.
Conclusions
Malaria upsurges usually have early warning signals and surveillance is a key health intervention to reducing their impact. Malaria surveillance and response, with precisely targeted multipronged activities, when led by local health authorities is an effective, efficient, and sustainable approach to managing such upsurges.
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.
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:
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]
Upon detecting an increase in malaria cases in 2018, the Nwoya DHT convened a stakeholder meeting with health workers from the public, private not for profit and private for profit HFs, as well as implementing partners, district technocrats and political leaders. A multi-sectoral management taskforce was formed which included key district sector leads from health, education, engineering, and community development, as well as implementing partners. A technical RRT was also setup, comprised of technical personnel, according to Uganda’s Guidelines for Preparedness and Response for Malaria Epidemics (Republic of Uganda MoH, 2012) e.g. environmental health officer, clinician, laboratory technician, Nurses, biostatistician, health educator and a logistician. This team of experts was responsible for the rapid assessment, mapping out the specific geographic areas most affected and identifying possible causes for increased infections. After the rapid assessment was completed, further detailed analyses were conducted, with Alero and Anaka sub-counties identified as the most affected sub-counties (see Figure 2).
HF record reviews and mapping exercises identified the specific villages within the sub-counties most impacted, to plan for targeted interventions. A field visit was carried out to the respective sub-counties to assess the awareness of the outbreak among the community and the availability of artemisinin-based combination therapy (ACT) and rapid diagnostic tests (RDTs) at the HFs and VHTs. The Nwoya district vector control officer did preliminary entomological surveillance in some villages and noted increased mosquito densities. A planning meeting was convened by the DHT to inform all relevant stakeholders of the assessment findings, mobilise resources and develop a comprehensive district response plan, based on the findings and guided by policy.[1] Interventions were categorised as immediate, intermediate and long-term, with immediate activities to treat cases and avert deaths; intermediate to bring down the epidemic and long-term to sustain the gains which were successfully achieved.Figure 2 Nwoya District and most affected sub-counties
Health workers from the affected areas were trained on integrated management of malaria including management of malaria in pregnancy. Pregnant women were encouraged to attend antenatal care (ANC) and receive intermittent preventive treatment in pregnancy (IPTp) for malaria and the district strengthened the referral linkage across the various levels of health care. Home visits were conducted to the VHT members across the district to mentor them on malaria epidemic response and orient them on their role in the response plan.
The HFs conducted test, treat and track outreach activities, as per the national malaria control plan (Republic of Uganda, 2014), in areas where out-patient department (OPD) records indicated high malaria cases. Of the 7,634 asymptomatic persons tested, 5,355 (70 percent) were positive for malaria (using RDTs). Confirmed cases were given ACTs, as per the national guidelines. Malaria outreach activities were also integrated into other activities such as the Expanded Program of Immunization (EPI), HIV/AIDS outreach, etc. These outreach activities were conducted by staff from the public HFs, with support from the various MoH implementing partners, including the UK’s Department for International Development (DFID) funded Strengthening Uganda’s Response to Malaria (SURMa) project.
The rapid response team monitored and ensured that there were enough malaria commodities (ACTs, RDTs, sulfadoxine-pyrimethamine (SP) for IPTp etc.) at the facilities and for the VHTs. Where necessary, the HFs provided the VHTs with integrated community case management (iCCM) commodities from their own supplies to boost the stock levels in the communities since commodities initially supplied under iCCM were consumed at a faster rate than envisaged. There was also redistribution of commodities from neighbouring districts to replenish the HF stock while the district waited for the National Medical stores (NMS) commodity distribution cycle.
SBCC played a key role and was conducted via places of worship, schools, health workers, community leaders, VHTs, a radio talk show and radio announcements/jingles. The messages focused on the importance of consistent use of LLINs and seeking immediate medical attention in case one felt feverish or unwell. The HFs also conducted malaria community sensitizations during outreach activities.
Unlike the previous upsurge, which was picked up by the media before being identified by the MoH, the Nwoya DHT was able to detect the 2018 upsurge from their own records, raise awareness among partners and the general public including the media, and respond in a timely manner; indicative of appropriate use of their own data. Targeted outreach activities reduced the reported malaria cases in those sub-counties with high positivity rates and the overall number of confirmed malaria cases in the district decreased, as reflected in the Normal Malaria Channel graphs of Nwoya for 2018 and 2019 (Fig. 3).
The upsurge was detected early by the DHT, with support from the DFID-funded SURMa project which provided the DHT with the malaria normal channel graphs, as well as training and mentoring on plotting and interpreting data for the DHT and HF teams. This support helped the district to strengthen their surveillance system and enabled them to monitor malaria case trends. Consistent monitoring of this information ensured the DHT could provide an immediate and appropriate response where necessary.
The district-led response strategy, which was applied collaboratively with implementing partners and across sectors, led to a reduction in the routinely reported malaria cases from 2,513 cases per week to 1,335 cases between week 43 in 2018 and week 10 in 2019.
The routine VHT follow-up and mentorship led to improved community-based malaria reporting and malaria data quality.
To ensure sustainability and relevance, it is important that the district take the lead in any malaria surveillance and response activities, with a management task force put in place, together with the technical RRT.
The management task force and RRT ought to be permanently in place, not only convened when prompted by an upsurge. Both teams should regularly review data (both epidemiological and entomological).
A local contingency plan should be in place and updated from time to time.
A generic national upsurge investigation and response plan should be developed, which can be adapted locally for the coordinated implementation of activities.
For effective services delivery, the district should strengthen and sustain rigorous use of data for monitoring and decision making at all levels of health management
Health facilities should use routine data surveillance to guide implementation and implement intensified responses in areas experiencing increases in confirmed malaria cases. Including targeted test, treat and track outreach, promotion of LLIN use, IPTp use amongst pregnant women and iCCM in eligible areas.
District Health Teams should mentor health workers to practice malaria test, treat and track. Many community members in the district have been found to be asymptomatic hence they do not go to the health facilities for testing and treatment. These cases then become malaria reservoirs among their community, increasing the chances of reinfection for those that get treatment. Tracking ensures that all sources of transmission in the households are managed, including the asymptomatic cases.
Commodities must also be rapidly at the disposal of health workers so they can act when required. Inter- and intra-district tracking and redistribution of necessary malaria control commodities, according to MoH policy, should be strengthened with proper documentation and accountability to minimise stock outs during upsurges when consumption is higher than anticipated.
Entomological surveillance provides important information on the vector and their contribution to the upsurges
Engaging the private sector as part of a multi-sectoral collaboration improves the effectiveness of the response to the upsurge and increases the opportunities for resource mobilisation.
Quality assurance is another important component of an effective surveillance system. To ensure quality data and proper decision making at all levels and accurate monitoring of malaria trends, biostatistician should cross check weekly surveillance reports from health facilities before sending them to MoH.
Promote integration of environmental sanitation into regular malaria interventions i.e. destruction of mosquito breeding sites through bush clearing, draining of stagnant water, destroying broken pots/tins/tyres etc.
Malaria upsurges usually have early warning signals and surveillance is a key health intervention to reducing the impact of such upsurges. Because an upsurge in one location can be easily masked by low case numbers in other areas if surveillance is only done at the district level, to be truly effective, surveillance must be carried out at the lowest operational administrative levels. It is vital that health workers keenly observe the disease data trends in their catchment areas so that they can detect any irregularities and act swiftly. Rapid response is key to averting what could otherwise result in avoidable high morbidity and associated mortality in the absence of a strong localised surveillance and response system. This case study demonstrates that malaria surveillance and response, with precisely targeted multipronged activities, when lead by local health authorities is an effective, efficient, and sustainable approach to managing inevitable malaria upsurges.
ACT Artemisinin-based combination therapy
ANC Antenatal care
DFID Department for International Development
DHIS District Health Information System
DHT District Health Team
EPI Expanded Program of Immunization
GMP Global Malaria Program
HFs Health facilities
ICCM Integrated community case management
IPTp Intermittent preventative treatment in pregnancy
IRS Indoor residual spraying
LLINs Long lasting insecticidal nets
MoH Ministry of Health
NMCP National malaria control programme
NMS National Medical stores
OPD Outpatient Department
PMI President's Malaria Initiative
RDT Rapid diagnostic test
RRT Rapid response team
SBCC Social behaviour change communication
SP Sulfadoxine-pyrimethamine
SURMa Strengthening Uganda’s Response to Malaria
UCC Universal coverage campaign
VHT Village health team
WHO World Health Organization
Not applicable
Not applicable
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
The authors declare that they have no competing interests
The United Kingdom’s Department for International Development
MF assisted with writing and editing the paper based on information provided by co-authors and literature reviews. All authors contributed to manuscript development and proof-reading.
Nwoya District Local Government and the rest of the districts in the SURMa Project Regions. SURMa Project Team Members (Malaria Consortium and UNICEF). Malaria Consortium Uganda Country Office, Regional Office, and Global Team Members.