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CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This section presents the literature related to the study based on the works of the scholars and is revealed on the basis of the objectives of the study.
2.1 Distribution of malaria among the children under 5 years
Malaria is a major cause of morbidity and mortality worldwide, especially in young African children. It is a major parasitic disease that can be prevented and treated (US PMI, 2009). Several efforts based on protection of individuals, households at community level (Warrell et al, 2002) have been initiated to ensure morbidity and mortality due to malaria is reduced. Currently several proven and cost effective malaria control interventions have been largely initiated in malarias areas. These include prompt treatment with Artemisnin Based Combination (ACTs), high coverage with LLITNs, Intermittent Preventive Treatment in pregnancy (IPTp) and Insecticide Residual Spray (IRS). These measures have significantly proven to reduce clinical and risks of malaria infection particularly in pregnancy and children under five years who are vulnerable groups to malaria.
Prevalence of malaria in young children has been reported in many studies from both developing and underdeveloped countries. In Democratic Republic of Congo, surveys which were conducted in 1980s and 2000 reported two fold increase of blood smears positivity from 17% in 1980s to 34% in 2000. In Tanzania the first national, population-based 2007-08 Tanzania HIV/AIDS Malaria Indicator survey (2007-08 THMIS) showed that 18% of children under five years of age had tested positive for malaria on the Mainland, whereby in rural areas higher prevalence of 20% compared to the urban areas of 8% was reported. There were marked regional variations that ranged from 0.4% in the highland areas around Arusha to 41.1% in the northwestern region of Kagera. The survey also showed an increasing prevalence by age from about 9% in infants (6-11 months) to 22% in children aged 2-4 years. Malaria prevalence showed a direct relationship with the socio-economic status and education of the mother of children under-five years of age. Households with lowest wealth quintile were more likely to test positive for malaria than those from households in the highest quintile.
More than 30000 cases of malaria are reported annually among travelers from developed world visiting malarious areas.(Leder K et al) With the shrinking globe, perennially prevalent malaria, therefore, remains an ever existing danger for humanity, in every part of the globe. In most areas, malaria and poverty co-exist, with the average GDP and average growth of per capita GDP in malarious countries being about one fifth (1/5) of those in non-malarious countries.
According to the(WHO 2013) and the Global Malaria Action Plan 3.4 billion people (half the world’s population) live in areas at risk of malaria transmission in 106 countries and territories .In 2012, malaria caused an estimated 207 million clinical episodes, and 627,000 deaths. An estimated 91% of deaths in 2010 were in the African Region.
Malaria is the leading cause of morbidity and mortality in Uganda especially in children under five years. Up to 70 per cent of outpatient cases and over 50 per cent of inpatient admissions in the under-fives are malaria cases. It is responsible for a specific death rate among this age group of 37/1000 and 18/1000 live births in high and low malaria endemic areas respectively or a total of 70,000–110,000 child health deaths annually. It is also the major killer of refugees and internally displaced people in Uganda.
Knowledge on malaria A number of studies have investigated differences in knowledge and reported health seeking behavior between men and women. Most found either no difference or those women had more limited decision-making and financial power to act. This was associated with failures and delays in seeking treatment, with differential understanding of malaria between men and women, and differential health-seeking behaviour. Women delayed seeking care until men were available, while men were less willing to spend on child health. (Al-Taiar et al 2009 & Oberlander and Elverdan 2000).These differences are critical when considering the main child-caring role of women and children‘s increased vulnerability to malaria.
2.2 Malaria prevalence by residence and region for children under 5 years
According to (Makundi et al, 2007) it was reported that the burden of malaria is greatest among poor people, imposing significant direct and indirect costs on individuals and households and pushing households into in a vicious circle of disease and poverty. Furthermore vulnerable households with little coping and adaptive capacities are particularly affected by malaria. Households can be forced to sell their foods crops in order to cover the cost of treatment (Wandiga et al, 2006.) Depleting household resources and leading to increased food shortages, debts, and poverty for the poorest households. The costs of malaria are highly regressive, with the poorer households spending a significantly higher proportion of their income on the on the treatment of malaria than their least poor counterparts.
According to the latest World Malaria Report 2015 (WMR, 2015), malaria transmission occurs in five of the six WHO regions, with Europe remaining free. Globally, an estimated 3.2 billion people continue to be at risk of being infected with malaria and developing disease, and 1.2 billion are at high risk .more than 1 in 1000 are at a high chance of getting malaria in a year. There were 214 million cases globally in 2015, of which 88% were from the African region, 10% from SE Asia region and 2% from Eastern Mediterranean region. There were an estimated 438000 deaths, 90% from Africa, 7% from SE Asia region and 2% from Eastern Mediterranean region.(WMR, 2015)in comparison, 198 million infections and 584 000 deaths were estimated in 2013.
Socioeconomic conditions of the community have direct bearing on the problem of malaria. Ignorance and impoverished conditions of people contribute in creating source and spread of malaria and hinder disease control strategy (Collins et al, 1997& Yadav et al., 1999). This was also evidenced by Filmer 2002) that high costs of malaria treatment may lead to delays in treatment seeking behavior, whereby he found that the poorest groups in a society did not seek care as much as the non-poor, and did so at lower level public facilities.
Health education communication is one of the key components in malaria control and prevention. Serious obstacles in most disease control strategies include lack of effective health information, education, and communication programs. Community and health providers need to understand the problem in all its relevant aspects, as well as be aware of the options available for improvement (Mboera et al, 2007).
The climate in Uganda allows stable, year round malaria transmission with relatively little seasonal variability in most areas. Malaria is highly endemic in the country affecting approximately 90% of the 34 million population . Indeed, some of the highest recorded infective mosquito bites per person year) in the world have been seen in Uganda, including rates of 1586 in Apac District and 562 in Tororo District (Okello et al., 2006) measured in 2001–02. The Uganda MOH estimates that the entomological inoculation rates (EIR) is >100 in 70%, 10–100 in 20%, and <10 in 10% of the country (Uganda Bureau of Statistics, 2010). However, these estimates are based on little data, as few entomological surveys have been carried out in the country. Transmission is unstable and epidemic-prone in extreme southwestern areas and in the vicinity of the Rwenzori Mountains in the west and Mt. Elgon in the east, all areas extending above 1,800 meters in altitude.
The 2009 UMIS measured a prevalence of malarial parasitemia, assessed based on microscopy, approximately 30–50% exists in children 6–59 months of age( Uganda Bureau of Statistics, 2010). Anemia was also very common, with a hemoglobin lees than 11 g/dl seen in well over half of children .Prevalence was high (38–63% by blood smear) in all regions of Uganda except the major city, Kampala with 5%. and in the southwestern region, which includes highland areas (12%). As expected, prevalence was lower in urban areas, with increasing educational levels of mothers, and with increasing wealth. These prevalence measures are consistent with very high and stable transmission of malaria in most of Uganda.
2.3 Malaria forecast
Because of the inadequacy of malaria case data from many sub-Saharan African countries, population infection prevalence can be used to enhance understanding of the level of malaria transmission and how it has changed over time. Nationally representative surveys of P. falciparum infection prevalence or parasite rate are increasingly being undertaken in sub-Saharan Africa. modeling can help to estimate the proportion of the population at risk that are infected at any one time, and the total number of people infected.
During 2013, an estimated 128 million people were infected with falciparum in sub-Saharan Africa at any one time. In total, 18 countries account for 90% of infections in sub-Saharan Africa; 37 million infections (29%) arose in Nigeria and 14 million (11%) in the Democratic
Malaria cases increased from 1,444,352 in 1995 to 2,923,620 in 1999 (WMR, 2012). The malaria rate has consistently increased in 20015. There is considerable malaria morbidity due to repeated low level and mostly non-febrile infections with the parasites resulting into chronic anemia in children and pregnant women particularly primigravidae. Severe malarial anemia is responsible for a case fatality rate of 8–25 per cent among paediatric admissions. It is responsible for nearly 60 per cent abortions or miscarriages. High levels of resistance to classical malaria drugs have resulted in increased malaria morbidity (PMI, 2009)
As the worldwide focus on malaria is shifting toward planning for eradication, it is remarkable that evidence for a decrease in the malaria burden is lacking in Uganda. One exception may be Kampala, the only major city in Uganda, where decreasing malaria prevalence cases have been noted anecdotally, although definitive data are lacking. A cohort study conducted from 2004 to 2008 noted a remarkable decrease in malarial incidence, although this finding was influenced by other factors, including treatment of all malarial illnesses with highly effective agents, aging of the cohort population, and provision of insecticide-impregnated bed nets (Clark et al., 2010).
Regular reports from the Uganda HMIS are likely highly inaccurate, suffering both from underreporting of fevers (as only episodes captured by the national public health system are reported) and overstatement of malaria diagnoses in febrile children without diagnostic confirmation (Rowe et al., 2009). Nonetheless, the HMIS data provide the only available direct measure of disease numbers across the country. In recent years, HMIS reported cases increased since the 1990s, with over 10 million cases reported each year .Notably, 60–80% of fever cases are estimated to be treated in the informal and private sectors (not assessed by HMIS), and it has been estimated that the total number of fever cases in Uganda in 2005 was 60 million (President’s Malaria Initiative , 2010). Factors that may have influenced changes in malaria reporting over time include the abolition of user fees for public sector health care in 2001, which led to increased attendance at public facilities and the subsequent roll out of the Home-Based Management of Fever strategy (Uganda Ministry of Health, 2005), which shifted care to community centers without links to HMIS reporting. Another relevant factor is the rapid increase in population of the country, suggesting that, if the overal number of episodes of malaria has been stable, the incidence has decreased somewhat. Overall, it is difficult to ascertain from available data whether the incidence of malaria has decreased or increased over the last decade, but clearly the incidence of the disease in Uganda remains very high.
