Running head: MALARIA IN UGANDA

Malaria in Uganda
Estelle Maassen
Western Washington University

Running head: MALARIA IN UGANDA

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Introduction

What if we lived a world where small children did not have to die from
preventable, treatable, unnecessary infectious diseases? What if everyone in
this world had access to the available treatment of diseases that are in fact
treatable? In Uganda, malaria continues to be one of the leading causes of
morbidity and mortality; this is especially true in children 5 years and
younger (Musoke, Karani, Ssempebwa, & Musoke, 2013article 2).
According to the CDC (2016), malaria is transmitted through the bite of
the female Anopheles mosquito. The mosquito bites a human infected with
malaria, the parasites then mixes with the mosquitos saliva. Once the
mosquito bites a new uninfected human, the parasite in the mosquitos
saliva will mix with the blood of the uninfected human. The parasite travels
to the liver where it lies dormant until the parasite matures. Once the
parasite leaves the liver and goes to the blood stream, the human can show
signs of active malaria. At this point an uninfected mosquito can pick up the
parasite from this newly infected human and continue the transmission cycle
(CDC, 2016).
The Anopheles mosquito lays its eggs in water, which then hatch into
larvae and finally into an adult mosquito (WHO, 2016). This mosquito
pursues a blood meal to nurture their eggs. Transmission occurs more often
in places where mosquito life span tends to lasts longer, and where
mosquitos prefer biting humans opposed to other animals. In Africa,
mosquitos have a long life span and prefer biting humans; this is why 90% of

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malaria cases occur in Africa (WHO, 2016). The WHO (2016) also suggests
that temperature, rainfall pattern, and humidity could all affect the longer
term survival of mosquitos. Transmission typically follows a seasonal pattern,
which is seen to peak during or even right after the rainy season (WHO,
2016).
In 2010, Uganda had more greater than 11 million cases of malaria,
which is the highest in Africa (Maxmen, 2012). According to Humphrey,
Katamba, & Rubahika, InUganda,malariaisendemicinover90%ofthecountrys

regionsandtheNationalMalariaControlProgramme(NMCP)estimatesthatbetween30
and50%ofoutpatientsvisits,1520%ofhospitaladmissionsand20%ofhospital
deathsareduetomalariawiththebiggestburdenbornbychildrenunder5yearsofage
andpregnantwomen(p.2,2016).Uganda has a disadvantage in the area of
malaria prevention. This is mostly due to the fact that Uganda has the
perfect environment for mosquito inhabitation: lush lands, wetlands, moist
soil, and great lakes. (article 7T). These beautiful environments offer year
round refuge haven for malaria causing mosquitos . (Maxman, 2012).
Malaria prevention
The female Anopheles mosquito usually bites at night once it has
entered the home (Musoke et al. 2013). One of the main goals in malaria
prevention is to reduce mosquito vectors, which transmit malaria to humans.
These interventions include using mosquito netting, screening doors and
windows, or reducing mosquito breeding grounds near homes. Mosquitos
breed in areas of standing water, so it is important to keepkeeping water

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covered, or ridding get rid of water sources near the househomes all
together decreases the chance of mosquito inhabitation. It is also important
to reduce vegetation near the homes because mosquitos use it as a resting
place (article Musoke et al., 2013). Using measures to decrease the entry of
mosquitos are become very effective ways to decrease the spread of
malaria. C, such as closing windows doors and doors windows early in the
evening to prevent mosquitos entry is just one examplefrom entering the
home (Musoke et al., 2013).. When mosquitos do enter the home it is
possible to use insecticides to rid the mosquitos though it is not the most
cost effective measureas effective as using long-lasting insecticide treated
bed nets (LLIN). It is important to have a barrier, such as long clothing or
mosquito netting, to prevent bites (Musoke et al., 2013). .When mosquito
infestation is decreased, the chances of being bitten by mosquitos are
decreased, and subsequently, the chance of malaria transmission declines
The most effective measure for decreasing malaria is the use of LLIN
(Humphrey et al., 2016article 3). LLINs are one of the most promoted
interventions against malaria vectors as recommended by the World Health
Organization (WHO). These nets are impregnated with pyrethroid insecticide,
which is toxic to mosquitos, and acts as a physical barrier between mosquito
vectors and humans to decrease the risk of malaria transmission (Humphrey
et al., 2016). There was a LLIN mass distribution campaignwhichcampaign,
which aimed to provide universal coverage in Uganda, which is described as
one net for every two people. From September 2012 to August 2014 over 20

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million LLINs were distributed to some 41 million people. After this mass
distribution of LLIN, Data from the 2014 Malaria Indicator Survey (MIS) was
used to evaluate the use of LLIN post mass distribution (Humphrey, 2016).
In the 2014 MIS, 5345 households were surveyed. Of those households,
1984 (37.71%) households were excluded because they did not reach
universal coverage, and 3361 (62.29%) households were included because
they did reach universal coverage. After mass distribution, a representative
sample of the entire Ugandan population found that 80% of the population
and 83% of children under 5 years old slept under the LLINs the night before
this survey took place (amongst households that achieved mass distribution)
(article 3Humphrey et al., 2016). According to the WHO, if 80% of the
population slept under the LLIN the night before the survey, than the
operation definition of success was achieved. Because of the mass
distribution campaign, access and use were increased in pregnant women
who were of childbearing years, and in children less than 5 years of age
(Humphrey et al., 2016). This outstanding success in use of LLINs from mass
distribution was a great factor in working to eliminate transmission of
malaria.
Though success was great, there were some concerning results that
arose from this study. The behavior change communication (BCC) sent a
strong message to the use of LLINs amongst children under five and
pregnant mothers, which lead to a decrease in use of LLINs in child 6-14
years old (Humphrey et al., 2016). The prevalence of malaria in this older

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child population is concerning, and drives a push to change the BCC

message. The message needs to be more inclusive to all populations in
Uganda in order to further increase LLIN use, especially as more of the
population gains access to LLINs through mass distribution (Humphry et al.,
2016). Also, during analysis of the 2013 mass distribution, it was found that
as family size increased the use of nets decreased. This was explained that
because so many people were sleeping in one area, sharing of LLINs became
more difficult, and some family members were left sleeping without a net.
So, in order for the mass distribution to be more effective, the definition of
universal coverage (1 net for every 2 people) may need to be re-evaluated in
order to more effectively cover larger households (Humphrey et al., 2016).
One major factor that is a barrier to malaria prevention in Uganda is
poverty (Musoke et al., 2013article 2). The fact is, most families cannot
afford mosquito netting which is one of the most basic tools in preventing
malaria. This becomes even harder when family size increases, and large
families are common in Uganda. If they families are not recipients of mass
distribution LLINs it is financially difficult for them most families to obtain
mosquito netting for their homes. Community Health Workers (CHWs) are
heavily utilized in rural areas of poverty that are hard to reach. They are
trained on basic principles of malaria prevention, and provide this
information in their assigned areas. CHWs work to provide valuable
information and teaching to vulnerable populations, and aim to improve
health through teaching (Musoke et al., 2016). CHWs are known for

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increasing access to healthcare, this is especially true in rural areas that are
difficult to reach. This The information and teaching from CHWs is valuable to
everyone in Uganda, but it isis it especially important for pregnant women
and children to receive information about malaria prevention due to their
vulnerability of malaria (Musoke et al., 2013article 2).

Malaria During Pregnancy

Malaria is a serious disease, and it becomes a greater health concern
when a pregnant woman is infected (Buregyeya et al., 2016). A study was
undertaken in Mukono district, bordering Lake Victoria in Central Uganda, to
try and understand the methods of malaria treatment and prevention in this
area. Malaria during pregnancy causes anemia in mothers and low birth
weight in infants (Buregyeya et al., 2016article 5). According to the WHO
(2016), if a pregnant woman lives in a high exposure area where levels of
acquired immunity tend to be high, she is less likely to experience negative
effects of malaria herself. Though, it is possible for parasites to be present in
the placenta leading to maternal anemia. Maternal anemia and placenta
parasitaemia can lead to low birth weight, which is an important contributor
to infant mortality (WHO, 2016). Tis is why it is important for mothers to
prevent malaria during pregnancy.
A study was undertaken in Mukono district, bordering Lake Victoria in
Central Uganda, to try and understand the methods of malaria treatment and
prevention in this area (Buregyeya et al., 2016). It is recommended that

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pregnant women receive at lease three doses of sulfadoxine-pyrimethamine

(SP) as intermittent preventative treatment (IPT) as well as use of LLINs as
prevention against malaria during the second and third trimesters of
pregnancy (Buregyeya et al., 2016 (2016). Utilization of SP-IPTs are
extremely low, and thisthis low use can causeleads to missed opportunities
for pregnant women to prevent malaria, about 26.7% of women receive only
two doses of SP-IPT (Buregyeya et al., 2016 (article 5). This information
shows that a large amount of women dont meet the recommended doses of
SP-IPTs increasing the chance of adverse effects during pregnancy.
Many factors play into the low utilization use of health based
interventions and antenatal care such as: financial constraints, long
distances to health facilitieshealth facilities, poor perceptions of healthcare,
and poor quality of care (Buregyeya et al., 2016article 5). There is misleading
and conflicting information that is presented in the private healthcare sector
in Uganda regarding the treatment and prevention of malaria. Some
healthcare providers properly prescribed SP-IPT for malaria prevention, but
also prescribed ATC or quinine, which is not recommended first line
treatment for pregnant women (Buregyeya et al., 2016). Less than 40% of
private sector health care providers in various settings understood the
proper first line treatment of malaria in pregnant women. Healthcare
providers in Uganda are overworked due to a shortage of HCPs, and quality
work is hard to maintain when the amounts of pregnant women become
overwhelming. HCPs in Uganda tend to burn out due to the overwhelming

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amount of antenatal care that is needed in addition to other disease burdens

in Uganda. Because of this, best interest is not always considered for
patients. . These results stem from the fact thatAlso, manyost providers
dont understand that pregnant women are a greater risk of malaria during
pregnancy, which could have very negative implications for pregnant women
and infants (Buregyeya et al., 2016article 5).
Many women in Uganda have difficulty attending the recommended
four antepartum visits and few receive the recommended three SP-IPTs
during pregnancy (Mbonye, Mohamud, & Bagonza, 2016article 4). There are
many reasons that women in Uganda do not receive proper antepartum care
or adhere to recommended SP for malaria prevention: they do not feel sick
and therefore do not see a need to seek out antepartum care or SP
treatment, the clinics are too far away, waiting hours in clinics were too long,
women were not aware of benefits of SP in pregnancy or were fearful of
negative adverse side effects, and they were sleeping under treatedusing
LLINs at nightnets and did not see need for SPs (article 4Mbonye et al.,
2016). These are just some of the highlighted barriers that come into play
that deter women in Uganda from seeking out and utilizing preventative
services while pregnant.
It is important for these barriers to be addressed in order to increase
the prevention of malaria in pregnant women (Mbonye et al., 2016article 4).
These findings highlight an important aspect of health, and that perception
of risk of any given disease is going to contribute to the preventative actions

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taken. Prevention in the form of SP and antepartum care are effective,

women in Uganda just do not always understand the value or importance of
these interventions. According to Mbonye (article 4 et al.,) It is shown that
a high proportion of the study population had attained secondary education
thus could appreciate health messages and the benefits of malaria
prevention in pregnancy and possibly adopting positive behavior practices
(p. 4, 2016). Creating education materials about the importance of malaria
prevention during pregnancy, and utilizing HCWs in rural communities could
have very beneficial outcomes or pregnant women and children. It could help
combat issues of non-adherence regarding preventative interventions. Once
again, HCWs come into play in order to help advocate for women, and
educate them on important matters that will impact their health and
pregnancy outcomes. (Mbonye et al, 2016article 4).
Social Implications of Malaria
It is apparent that many things that need to take place in order to help
prevent malaria, and ensure that unnecessary deaths from malaria do not
occur. There are several interventions in place to try and prevent infection of
malaria, but without proper education and follow through those interventions
are not going to be effective. If people do not have access to the necessary
resources in order to implement or maintain these interventions it seems as
though the cycle of malaria will be difficult to stop. Malaria continues to be a
prominent issue in Uganda. Though there are many interventions in place
that can help to decrease the prevalence of malaria, it does not seem as

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though the interventions are always effective due to a lack of education.

The use of community health workers seems to be one of the greatest
tools in the implementation of effective interventions (Musoke et al., 2013).
Since basic educational materials have potential to be highly effective, it is
important that health care workers are taking on the task of teaching
community members about malaria prevention, especially in areas of
poverty. They cycle of preventing malaria transmission and issues with
poverty in Uganda can be difficult to break. People living in poverty may not
be as receptive or accepting of preventative measures against malaria. This
could further increase morbidity and mortality rates as well as further
increase instances of living in poverty due to costs of treatments, frequent
hospitalizations for malaria, or transportation associated with malaria
infections. As previously stated, a large number of individuals in Uganda
have had some form of education and are very capable of learning and using
new information. This is why it is important to utilize health care workers to
promote health and increase healthcare access (Musoke et al., 2013).

Conclusion
Most often, deaths from malaria occur in the poorest populations.
These deaths are unnecessary, and occur almost exclusively because of the
poverty that is present (Ricci, 2012). Housing amongst the poor, which is
often times accompanied by overcrowding, is something that puts them at
increased risk of contracting malaria. The more people present in a home

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increases the area that needs to be covered by mosquito netting which is

often times not feasible or attainable for some families who are in spread out
sleeping arrangements. Homes may also be feebly constructed due to
availability of materials, which increases the risk of mosquito infestation in
homes. Malnutrition that often times accompany poverty also increases the
risk for infection with malaria, mostly due to a lack of immunity (Ricci, 2012).
There is an ongoing theme that poor economic and social conditions and lack
of education are closely linked, which leads to increased risk of malaria
infection and poor health outcomes. One of the most important aspects to
address are the barriers that are faced by poor people around the world, and
until their barriers are assessed and bridged it will be very hard to fight off
malaria. Prevention of malaria begins when access is increased, and it is
possible for people to be treated and cured regardless of education level of
socioeconomic status. Access to healthcare services and education must be
driving forces to help prevent malaria (Ricci, 2012). One of the worst aspects
of malaria in Uganda is that it is preventable, it is treatable, and deaths
resulting from malaria infections are completely unnecessary.

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References
Buregyeya, E., Mbonye, A. K., Rutebemberwa, E., Clarke, S. E., Lal, S., Hansen, K. S.,
Magnussen, P., LaRussa, P. (2016). Treatment and prevention of malaria in pregnancy in
the private health sector in Uganda: implications for patient safety. Malaria Journal,
15(212), 1-7. DOI 10.1186/s12936-016-1245-2
Centers for Disease Control and Prevention. (2016). Malaria. CDC. Retrieved from
https://www.cdc.gov/malaria/about/faqs.html
Humphrey, W., Katamba, H., Rubahika, D. (2016). Use of long-lasting insecticide-treated
bed nets in a population with universal coverage following a mass distribution
campaign in Uganda. Malaria Journal, 15(311), 1-8. DOI 10.1186/s12936-016-1360-0
Maxmen, A. (2012). Death at the doorstep: even a cure is not preventing deaths from
malaria in Uganda. Poor education and limited access to healthcare are among
reasons why. Malaria Outlook, 484, 519-521.
Mbonye, A.K., Mohamud, S. M., Bagonza, J. (2016). Perceptions and practices for

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preventing malaria in pregnancy in a peri-urban setting is south-western Uganda.

Malaria Journal, 15(211), 1-5. DOI 10.1186/s12936-016-1246-1
Article 2
Musoke, D., Karani, G., Ssempebwa, J. C., Musoke, M. B. (2013). Integrated approach to
malaria prevention at household level in rural communities in Uganda: experiences
from a pilot project. Malaria Journal, 12(1), 1-7. DOI 10.1186/1475-2875-12-327
Article 3
Humphrey, W., Katamba, H., Rubahika, D. (2016). Use of long-lasting insecticide-treated
bed nets in a population with universal coverage following a mass distribution campaign in
Uganda. Malaria Journal, 15(311), 1-8. DOI 10.1186/s12936-016-1360-0
Article 4
Mbonye, A.K., Mohamud, S. M., Bagonza, J. (2016). Perceptions and practices for
preventing malaria in pregnancy in a peri-urban setting is south-western Uganda. Malaria
Journal, 15(211), 1-5. DOI 10.1186/s12936-016-1246-1
Article 5
Mbonye, A. K., Buregyeya, E.,Mbonye, A. K., Rutebemberwa, E., Clarke, S. E., Lal, S.,
Hansen, K. S., Magnussen, P., LaRussa, P. (2016). Treatment and prevention of malaria in
pregnancy in the private health sector in Uganda: implications for patient safety. Malaria
Journal, 15(212), 1-7. DOI 10.1186/s12936-016-1245-2
Article 7
Maxmen, A. (2012). Death at the doorstep: even a cure is not preventing deaths from
malaria in Uganda. Poor education and limited access to healthcare are among reasons
why. Malaria Outlook, 484, 519-521.

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Article 8
Ricci, F. (2012). Social implications of malaria and their relationships with poverty.
Mediterranean Journal of Hematology and Infectious Diseases, 4(1), 1-10. DOI:
10.4084/MJHID.2012.048

World Health Organization. (2016). Malaria Fact Sheet. WHO. Retrieved from
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http://www.malariamaps.hps.scot.nhs.uk/images/malariamaps/uganda/uganda.gif

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