Research consultancy
2.1 Malaria Prevalence
Globally infant deaths are ranging from 4-5 to more than 100 per live births. It is estimated that 20.5 million LBW infants were born in 1995. Prevalence of infant mortality per 1000 live birth ranged from 6 to 77 in developed countries including United Kingdom, United States. LBW in the same counties ranged from 5.2% to 28.2% where as the pre term delivery ranged from 4.6% to 24% of all live births(1) A snapshot of progress since 2005 showed each year at least 4 million new born die world wide which is unacceptably high number given that low cost solutions exist to save these lives. Neonatal mortality account for 40% of all under fives deaths.
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.
The time of birth and first days of life are the riskiest period in human life span. Each year 3 million babies die in the first week of life and up to two third (2/3) of these die in the first 24 hours of life. In India alone, more than 1 million newborns die every year(7). The study which was carried out at King Fahad showed the perinatal mortality rate was 34.9% (65/186)(8). In another study from Guatemala found among 671 infants born in 4 rural ladino villages, 15.2% had birth weights < 2500 g. The prevalence of LBW of 41.3% among 415 live, singleton births.
Sub Saharan Africa remains the most dangerous region in the world for the baby to be born as 1.16 million babies die each year in the first 28 days of life. About 0.5 million Sub Saharan Africa babies die on the day they are born most at home and uncounted. Each year in Sub Saharan Africa, 30 million women become pregnant, and 18 million give birth at home without skilled care and therefore each day in Africa; 3,100 newborns die, and another 2,400 are stillborn, 9,600 children die after their first month of life and before their fifth birthday and1 in every 4 child deaths (under five years) in Africa is a newborn baby. Nigeria has the world highest new born mortality rate at 66 deaths per 1000 birth. Half of African’s 1.16 newborn deaths occur in just 5 countries, Nigeria, Democratic Republic of Congo, Ethiopia, United Republic of Tanzania and Uganda. The report found two third (2/3) up to 800000 of new born death in Sub Saharan Africa in a year could be saved if 90% of women and babies received feasible low cost health intervention like immunization, providing a skilled attendant at birth, etc which would have needed only 1.39USD per capital.
More than 30000 cases of malaria are reported annually among travelers from developed world visiting malarias 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 malarias countries being about one fifth (1/5) of those in non-malarias 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.
2.2 Malaria distribution.
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 Southeast Asia region and 2% from Eastern Mediterranean region.(WMR, 2015)in comparison, 198 million infections and 584 000 deaths were estimated in 2013.
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 parasites, 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 Forecast malaria prevalence for children aged below 5 years
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 P. 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 pediatric 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 overall
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.
