Malaria Quarterly Bulletin Issue 10: April — June 2015 Uganda Ministry of Health | National Malaria Control Program | P.O. Box 7272 | | Uganda

Editorial Contents 1. Editorial and report highlights……………...….page 1 This is the 10th issue of the Uganda Malaria 2. Malaria Interventions……………………………....page 2 Quarterly Bulletin that focuses on the second quarter 3. Malaria Burden…………………………...……...…..page 3 of 2015. The aim of this bulletin is to inform district, 4. Laboratory diagnosis…………………………….….page 4 national, and global stakeholders on progress achieved 5. Treatment practices……………………….……...…page 5 and challenges encountered in malaria control in 6. Uganda Malaria Surveillance Project ………..page 6 Uganda. Most importantly, it is to encourage use of this 7. Special Topic: EPR ……………………………………..page 7 information at all levels in order to foster improvement 8. District malaria burden……………………………..page 8 of our efforts and to highlight achievements and create 9. Malaria burden maps… …………………….....page 10 awareness for increased resource mobilization& alloca- tion in order to maintain the gains we have achieved. 10. Indicator definitions……………………………....page 11 2015 Q2 Report highlights In this issue, we present HMIS and Malaria Reference data under the UMSP, representing • Overall, malaria burden, both the out-patient and in-patient, has risen rapidly to more than coverage of malaria interventions, malaria burden, double the malaria burden in this quarter when laboratory and treatment practices. We also present compared to the first quarter. the guidelines of Malaria Epidemic Preparedness and • A malaria epidemic was confirmed, from April, in Response as the special edition topic for this quarter. 10 northern districts. This follows the most significant malaria related event • Close to 50% of reported malaria cases, from 38%, are laboratory confirmed malaria. in this quarter, which was the confirmation of an • The number of doses of ACTs consumed still Epidemic in the ten former Indoor residual spraying remains at twice as much as the reported districts of Northern Uganda. The knowledge and use of malaria cases. these guidelines is of most relevant now as we strive to maintain the achieved low malaria burden. Editorial Team National Malaria Control Program In a bid to strengthen malaria surveillance focused Okui A Peter, Program Manager Katamba Henry on the district level, we have introduced district level Denis Rubahika Agaba Bosco malaria maps with colour codes to supplement and Mathias Mulyazawo ease data interpretation and improve usage. Vincent Katamba Wanzira Humphrey Additionally, we shall be highlighting the districts that Resource Centre Mukoyo Eddie need urgent action in the district level malaria burden Kyozira Carol Kissa John table. World Health Organisation Katureebe Charles We are happy to hear from you regarding this US President’s Malaria Initiative Kassa Belay publication, and we welcome your contributions to sub- BK Kapella sequent issues. Thank you again and we hope this will Uganda Malaria Surveillance Project Ruth Kigozi be an informative reading for you. African Leaders Malaria Alliance Gasasira Anne 1

HMIS reporting rates • HMIS data comes from all government, private-not- for-profit and some private -for-profit health facilities.

• Over 90% of such expected health facilities send their monthly reports to the HMIS.

• Of these, just over 80% send their reports within the first two weeks of the following month.

Malaria Intervention updates • Routine ante natal (ANC)LLIN distribution and intermittent preventive treatment in pregnancy (IPTp) with Fansidar continues to be the major malaria interventions among for pregnant mothers. • The proportion of pregnant women attending their first ANC visit and receiving the first dose of IPTp was just above 80% in this quarter just like in the first quarter ,of this year.

• Those receiving the second dose of IPTp was 20% lower than IPTp 1. However, in this quarter, IPTp 2 coverage rose from 50 to 60% when compared to the first quarter. • The proportion of pregnant mothers attending their first ANC and receiving an LLIN drastically dropped from 56% to 20% by end of the second quarter

• 15 districts received IRS in this quarter, one under the Ministry of Health (Kumi) and 14 ABT associates/ PMI/DFID supported districts (Budaka, Bugiri, Butaleja, , Namutumba, ,Serere, , Amolator, Dokolo, Kabaremaido, Lira, Otuke and ). Preparations are underway for district to be sprayed under the Ministry of Health. 2

Malaria Burden

Out-patients

• The number of monthly malaria cases diagnosed (lab confirmed and clinical) and malaria incidence rapidly doubled in this quarter from the lowest (829,548) recorded in over two years to the highest (1,629,237)since July 2013. • A similar trend of increasing malaria cases among children under 5 years doubled from 238,961 cases by end of March 2015 to over 500,000 cases by June 2015. • This surge in malaria burden is probably attributable to seasonal- ity, drop in intervention coverage (especially IRS and LLINs) and inadequate malaria related behavior change communication

In-patients

• A similar trend was also observed among those admitted to hospital due to malaria with the numbers/malaria incidence tripling from the lowest in the last 2 years (36,863) to the sec- ond highest in the same period (94,490) • The number of pregnant women admitted to hospital doubled in the second quarter when compared to the first quarter of this year. • However, the case fatality rate was still at less than 1% of all malaria admitted patients.

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Malaria diagnosis

Comparison of reported Malaria cases with laboratory test done • RDTs contribute over 70% of all the malaria laboratory tests performed in this quarter. • The comparison of reported malaria cases with laboratory test done followed the same trend, with increasing tests done similar to the increasing reported malaria cases. However, the number of tests done was still higher than the reported malaria cases.

Test positivity rate

• The test positivity rate in this quarter also rose from 38% in the first quarter of 2015 to close to 50% of all malaria tests done.

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Malaria diagnosis

Proportion of laboratory confirmed cases among all malaria diagnosed cases

• Among those diagnosed/ reported to have malaria, the average proportion of laboratory confirmed cases in this quarter was 58% as compared to the 41% of the first quarter.

Treatment practices

ACTs consumed

• The number of ACT doses prescribed also rose in this quarter following the same trend like the reported malaria cases. However, the number of ACTs rise was steeper and is still more than twice as much as number of malaria cases diagnosed.

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Malaria Reference Centers There are 32 Malaria Reference Centres (MRC) under the Uganda Malaria Surveillance Project (UMSP), and for this bulletin issue, we shall focus our data on the Test positivity rates of the Northern Uganda Reference centers. Overall, there is an upward trend of TPR in most of the MRC sites, evidence that complements and supports the presented HMIS data. Awach, Lalogi, Patongo and Pajule had IRS in Nov-14 while Amolatar, Do- kol, Alebtong and Orum had IRS in Jan 2015

Amolatar Dokolo Alebtong Orum IRS 1

0.8

0.6

0.4

0.2

0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

Aduku Anyeke

0.8

0.6

0.4

0.2

0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

Awach Lalogi Patongo Pajule

IRS 1 0.8 0.6 0.4 0.2 0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

Amolatar Dokolo Alebtong Orum IRS 1 0.8 0.6 0.4 0.2 0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 6

Special Topic: Malaria Epidemic Preparedness

• Towards the end of May 2015, three of the former 10 IRS districts in Northern Uganda (, and Kitgum) reported an increase in malaria cases to the NMCP, Ministry of Health. • A review of the weekly surveillance data received from the 10 former IRS intervention districts (, Kole, Gulu, Amuru, , Pader, Agago, Kitgum, Oyam and Lamwo) indicated that there were upsurges in weekly Malaria cases reported beyond the average threshold starting from weeks 16 to 26. The data was indicative of a “Malaria Outbreak” in these districts as shown in the graph below (of note– HMIS could only provide two complete years of weekly data for 2013 and 2014)

• The NMCP with the support of the Epidemic and Surveillance division has been working with the affected districts to ensure that this epidemic is brought under control by: 1. Working with the district per- sonnel to strengthen surveil- lance systems 2. Coordinate with the National Medical Stores to ensure delivery of emergency antimalarials. 3. Designing and implementa- tion of BCC messages on ma- laria prevention, especially use of LLINs and treatment. 4. Coordination with the blood bank to ensure blood availability for those with severe anaemia HMIS could only provide two complete years of weekly data for 2013 and 2014 Guidelines for malaria epidemic preparedness and response • The National Malaria Control Program has taken the following steps in an effort to prevent and /reduce the impact malaria epidemics through the following: 1. Distribution of the Epidemic Preparedness and Response guidelines to all districts and health facility levels for reference and also start training district and health facilities personnel. 2. Activation of the malaria epidemic preparedness and response team at the National level for ease communication in the event of an epidemic and strengthen coordination of the national EPR with district leadership. 3. Activation of the district epidemic management task force with the surveillance, logistics and BCC sub- committees 4. Activation of the rapid response teams for malaria to monitor malaria trends and implement interventions 5. Strengthen behaviour change communication focusing but not limited to LLIN usage, IPTp uptake and early treatment seeking in case of suspected malaria symptoms. 6. Emergency stock up of supply of anti-malarials (ACTs and Artesunate) for rapid treatment to reduce dis- ease burden and reduce mortality. 7. Reactivation of the community village health teams stocked with anti-malarials and rapid diagnostic tests

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District Malaria burden 2011 DHS regions District Malaria Incidence % difference 2014 Q2 2015 Q1 2015 Q2 2015 Q2 - 2015 Q1 2015 Q2 - 2014 Q2 Central 1 55 37 79 114 44 Central 1 193 101 164 62 -15 Central 1 79 51 86 69 9 Central 1 103 82 93 13 -10 Central 1 76 56 133 138 75 Central 1 70 46 67 46 -4 Central 1 404 289 299 3 -26 Central 1 District 101 59 106 80 5 Central 1 District 122 57 90 58 -26 Central 1 District 179 107 162 51 -9 Central 1 District 68 87 67 -23 -1 Central 1 82 86 56 -35 -32 Central 2 94 65 92 42 -2 Central 2 89 83 96 16 8 Central 2 District 100 71 96 35 -4 Central 2 District 52 43 64 49 23 Central 2 District 61 35 87 149 43 Central 2 Luwero District 126 80 86 8 -32 Central 2 District 126 91 133 46 6 Central 2 99 64 92 44 -7 Central 2 78 67 80 19 3 Central 2 116 66 72 9 -38 Central 2 211 121 153 26 -27 East Central 117 115 93 -19 -21 East Central 154 153 142 -7 -8 East central 72 63 80 27 11 East Central District 137 110 121 10 -12 East Central 130 120 138 15 6 East Central District 105 98 101 3 -4 East Central 170 120 144 20 -15 East Central 152 119 98 -18 -36 East Central District 114 87 90 3 -21 East Central 162 161 138 -14 -15 East Central 173 153 146 -5 -16 Eastern 91 65 112 72 23 Eastern 204 136 117 -14 -43 Eastern 96 45 83 84 -14 Eastern 80 48 68 42 -15 Eastern 150 88 87 -1 -42 Eastern District 133 104 119 14 -11 Eastern 219 179 168 -6 -23 Eastern District 146 99 155 57 6 Eastern 143 115 104 -10 -27 Eastern 230 162 256 58 11 Eastern 148 89 80 -10 -46 Eastern 124 98 152 55 23 Eastern 136 75 90 20 -34 Eastern 78 45 62 38 -21 Eastern District 105 51 73 43 -30 Eastern 112 77 111 44 -1 Eastern 132 129 96 -26 -27 Eastern 185 87 137 57 -26 Eastern District 103 14 104 643 8 1 Eastern 248 59 228 286 -8 Eastern Tororo District 196 66 114 73 -42

2011 DHS regions District Malaria Incidence % difference 2014 Q2 2015 Q1 2015 Q2 2015 Q2 - 2015 Q1 2015 Q2 - 2014 Q2 Kampala Kampala District 60 38 46 21 -23 Karamoja 292 212 288 36 -1 Karamoja 52 44 63 43 21 Karamoja 80 63 84 33 5 Karamoja 89 84 109 30 22 Karamoja 125 93 126 35 1 Karamoja 120 95 122 28 2 Karamoja 74 64 89 39 20 North 74 23 93 304 26 North 76 29 60 107 -21 North 139 82 88 7 -37 North 45 56 204 264 353 North 47 47 119 153 153 North 153 67 109 63 -29 North 79 52 184 254 133 North 34 42 128 205 276 North 43 10 73 630 70 North 20 40 181 353 805 North 110 58 85 47 -23 North 88 123 331 169 276 North 132 72 143 99 8 North 54 17 78 359 44 North 43 15 99 560 130 South West 57 23 31 35 -46 South West District 77 65 74 14 -4 South West District 146 137 161 18 10 South West 149 96 108 13 -28 South West District 15 9 10 11 -33 South West District 137 45 64 42 -53 South West 145 127 101 -20 -30 South West 22 14 15 7 -32 South West District 76 47 49 4 -36 South West 97 77 84 9 -13 South West 140 95 84 -12 -40 South West District 84 73 99 36 18 South West 121 75 78 4 -36 South West 83 66 104 58 25 West 146 93 124 33 -15 West Nile District 153 110 288 162 88 West Nile 115 64 117 83 2 West Nile 140 86 168 95 20 West Nile 107 66 98 48 -8 West Nile District 187 101 172 70 -8 West Nile 64 71 80 13 25 West Nile 97 75 83 11 -14 Westen 133 84 118 40 -11 Western 138 115 167 45 21 Western District 143 53 105 98 -27 Western 95 69 99 43 4 Western 104 79 119 51 14 Western 105 54 87 61 -17 Western District 93 34 58 71 -38 Western 82 54 95 76 16 Western District 132 98 157 60 19 Western 51 37 85 130 67 Western 110 43 89 107 9 -19 Western 65 49 62 27 -5

Maps of Malaria burden by district In this issue we introduce district level malaria maps covering the three quarters considered in this bulletin. The data presented here is number of cases in each quarter for each district per 1,000 population. We hope this will ease district level interpretation of malaria burden at the district level and for quick inter- vention. Additionally, the maps show the changes of malaria burden from one quarter to the next.

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Indicator definitions • Malaria cases reported/diagnosed comprises both laboratory confirmed and clinically diagnosed cases • Absolute number of malaria cases (OPD and IPD) and number of laboratory diagnostic tests done (Microscopy and Rapid diagnostic tests) during the month • Malaria incidence : Number of malaria cases diagnosed per 1000 population per month( in graphs) and quarter( in tables) • Case fatality: Percentage of deaths among all malaria related admissions • Comparison of reported malaria cases with laboratory tests done : Total laboratory tests done divided by the total malaria reported cases. • Test positivity rate: Percentage of malaria positive laboratory tests among all tests done (Microscopy and RDTs) • Proportion of diagnosed cases with a positive laboratory test • IPTp1, IPTp2 and ANC coverage: Percentage of pregnant mothers attending their first Ante natal visit who receive IPTp1, IPTp2 and ANC LLINs • Reporting completeness: Percentage of monthly reports received from health facilities in relation to the expected • Reporting timeliness: Percentage of monthly reports received from the health facilities within two weeks of end of month. • Malaria prevalence by microscopy among children 0-59 months is the proportion of children in the community in that age range with a positive blood slide result for malaria.

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