Malaria symptoms can start within 10 to 15 days of being bitten by an infected mosquito, but it can take up to a year for them to show. PHOTO/FILE
References to mosquitoes, the primary malaria vectors, date back to ancient texts such as the Bible and the Quran. Although there are more than 4,000 mosquito species, only a fraction, primarily the anopheles genus, are capable of transmitting malaria. The anopheles gambiae complex, a species discovered in Africa, is among the most efficient carriers of the malaria parasite.
Mosquitoes contract the parasite from humans and transmit it to others during feeding, perpetuating a deadly cycle. Today, malaria predominantly plagues tropical regions such as Uganda, where a favourable climate supports mosquito proliferation.
Uganda’s malaria burden is staggering, with some areas such as Apac District recording the world’s highest density of infected mosquito bites at 1,560 per person annually.
According to the World Health Organisation (WHO), at 478 cases per 1,000 people per year, Uganda’s malaria incidence rate is one of the highest globally. The disease claims approximately 273 lives daily, translating into an annual death toll of 70,000 to 100,000 people.
Malaria symptoms can start within 10 to 15 days of being bitten by an infected mosquito, but it can take up to a year for them to show. While malaria traditionally affected children under the age of five and pregnant women, its impact has expanded to older children, adolescents, and even adults.
Dr Sabrina Kitaka, a paediatric infectious diseases specialist, highlights this troubling shift, recounting the case of a 41-year-old man who succumbed to severe malaria due to delayed diagnosis and treatment.
“What we are seeing today is that the epidemiology of malaria has completely changed, and it baffles us. We are seeing adults and older children, between 12 and 19, dying of malaria,” she says.
Between March 2020 and 2024, malaria fatalities in Uganda exceeded 50,000, compared to around 5,000 deaths caused by Covid-19 during the same period.
Challenges in diagnosis and treatment
Malaria often mimics other illnesses, making timely diagnosis challenging. However, delayed medical intervention and self-medication exacerbate the problem.
“If symptoms persist despite treatment, return to the hospital. The second-day review is critical in ensuring that the prescribed antimalarials are effective,” Dr Kitaka advises, underscoring the importance of vigilance.
Resistance to antimalarial drugs is a growing concern with research indicating that resistance to first-line treatments has risen from 0.2 percent to six percent, complicating efforts to control the disease. Additionally, the emergence of new malaria strains, such as Plasmodium ovale and Plasmodium knowlesi, further complicates diagnosis and treatment.
“We have now developed a protocol to back up treatment. If a patient has a severe form of malaria, we must start them on tesunate (an antimalarial drug or injection). On Day Two, we will repeat the blood smear and if the results are still positive, then we may have to switch to another line of treatment, which is quinine,” Dr Kitaka adds.
Dr Jimmy Opigo, the assistant commissioner in charge of the Malaria Control Division, says research from the Ministry of Health (MoH) shows that treatment failure and resistance are caused by treatment non-completion.
“It has been found that when they go to drug shops, on average, Ugandans buy seven tablets out of the recommended 24. This is only one-third of the treatment. So, they take the coartem for one or two days and relax or only take Panadol, which they mix with herbs. Several people easily progress to severe malaria,” he elaborates.
Dr Myers Lugemwa, a renowned malariologist, says there are people who are reservoirs for the disease, calling them the most dangerous people. These reservoirs are the carriers that infect mosquitoes although they do not show clinical signs of malaria.
“Some do not even go to health facilities. They are moving around in suits and ties like yours but with the parasites lodging into their bodies. Some types of parasites stay much longer in the body. For instance, a mutant can stay in the liver for two years. That is why some people who come to the tropics return home seemingly healthy only to get a fever some months later,” he says.
The health ministry is also bothered by the volume of low-quality malaria supplies on the market, which is about 20 percent. However, Dr Opigo says the National Drug Authority (NDA) is trying to close that gap.
“All malaria supplies brought in through the right channels are subjected to tests. However, some people dodge the ports of entry and smuggle in the drugs. We have requested that the NDA increase field testing. Currently, they sample by trigger of a complaint. But, there could be others where no one is raising a complaint,” Dr Opigo explains.
Evolving mosquito behaviour
Mosquito behaviour is changing, thus presenting new challenges for malaria control. Historically, mosquitoes used to bite during nighttime hours, allowing people to protect themselves using bed nets.
However, recent studies reveal that mosquitoes bite earlier in the evening and even outdoors, following children to schools and classrooms.
Climate change and unpredictable weather patterns have exacerbated these challenges, particularly in regions such as Karamoja, where intervention timings no longer align with shifting rainy seasons.
“For example in Karamoja, the rainy season used to last five months. We knew that during these months we had to give the children prophylaxis. Now, the rainy season takes a long time to start and even lasts longer. So, climate change, climate variability with floods, and unpredictable patterns compromise our actions,” Dr Opigo says.
Dr Lugemwa says an invasive mosquito vector, Anopheles stephensi, has come into play. This subtropical species is mostly found in the Indian subcontinent, the Middle East, and the South Asia region. In 2013, the species was discovered to be established on the African continent in Djibouti, Ethiopia, and Sudan.
Resistance to antimalarial drugs is a growing concern with research indicating that resistance to first-line treatments has risen from 0.2 percent to six percent, complicating efforts to control the disease. FILE PHOTO
“Anopheles stephensi has been discovered in Turkana County in Kenya but we are watching out for it. That one can breed anywhere, even in a small water collection, such as that found in the cover of a water bottle. And, it is very efficient,” he elaborates.
The Anopheles stephensi vector on the African continent appears to have several insecticide resistances.
Addressing severe malaria
Uganda faces a uniquely aggressive malaria parasite, Plasmodium falciparum, which increases the risk of severe malaria, fivefold. Severe malaria accounts for five percent of all cases in Uganda and is characterised by complications such as anaemia, convulsions, and acute kidney injury.
Despite an 80 percent survival rate, 20 percent of severe cases result in fatalities. Dr Jimmy Opigo emphasises the need for timely intervention.
“Severe malaria is a medical emergency, but people do not treat it as such. People have normalised malaria, they are procrastinating. They treat everything as a fever, hangover, or just feeling bad and take paracetamol. They cannot know that it could be malaria,” he laments.
This laxity gives malaria parasites a chance to multiply in the body. Worryingly, severe malaria is now hitting the kidneys, and sending several patients to hospital for dialysis services.
“We are seeing more children with malaria-induced acute kidney injury. When they come in, it is important that we first hydrate them before putting them on the correct antimalarials. If they are developing acute kidney injury, in most cases, they may have to be switched to the second line of treatment for severe malaria,” Dr Kitaka warns.
Malaria-induced anaemia poses unique challenges, particularly during peak malaria seasons. For instance, there is a surge in cases in December during the rainy season. Blood shortages, compounded by reduced donations during school holidays, hinder treatment efforts.
The planned rollout of the malaria vaccine in April 2025 is a breakthrough in Uganda’s fight against the disease. Dr Ruth Aceng, the health minister, announced that the country would receive the largest allocation of vaccines globally. The R21 vaccine, a cost-effective option chosen over the expensive Glaxo-branded vaccine, will be administered exclusively to children.
“The vaccine will protect children from the serious burden of malaria by reducing severe cases and hospitalisations. We are very hopeful that it will put a dent in the malaria burden. I encourage Ugandans to wait for the free vaccine rather than purchasing the costly Glaxo version,” Dr Aceng said in an earlier interview.
The distribution of the vaccine is funded by the Gavi Vaccine Alliance and the government of Uganda.
Integrated strategies for malaria control
Uganda employs an integrated vector management strategy, including indoor residual spraying, distribution of insecticide-treated mosquito nets, larviciding, and public health education. However, resistance to insecticides necessitates periodic rotation of chemicals as recommended by WHO.
Dr Lugemwa highlights the importance of eliminating the malaria parasite to break the transmission cycle. Stopping transmission means the country can achieve elimination.
“Uganda is a conservative society and there is a need for behavioural change in the fight against malaria. So, even though malaria is worldwide, those countries that have been able to eliminate it are implementing the globally recommended strategies more than we have. Unfortunately, in Uganda, as recently as last year, we wanted to spray Kibuku District. However, the district authorities refused, demonised the exercise, and politicised it,” he says.
He adds that because the district was not sprayed, 80 percent of all the deaths and blood transfusions at Mbale Regional Referral Hospital were from Kibuku. Spraying the district would have helped surrounding districts to reduce the number of malaria cases, it is believed.
“So, it is not that we have more mosquitoes than other places in the world, but sometimes, we may not be in a position to implement every strategy that is aimed at eliminating malaria in one go. There is no magic bullet that can eliminate malaria. It requires a prolonged approach involving indoor spraying and clearing areas where mosquitoes breed,” Dr Lugemwa advises.
A call to action
As a landlocked country, Uganda’s malaria elimination efforts require cross-border collaboration. The Ministry of Health works with neighbouring countries to coordinate interventions and tackle the disease’s transnational nature.
“The ministry has developed a malaria elimination strategy that is awaiting approval. Once adopted, the government will work with Parliament to mobilise resources and implement targeted interventions, including cross-border collaboration,” Dr Opigo says.
Dr Kitaka and Dr Opigo emphasise the need for a collective response involving policymakers, health workers, researchers, and the public. Increasing awareness, ensuring proper use of mosquito nets, and promoting timely medical care are crucial. Dr Opigo advocates for the establishment of well-equipped sickbays in schools to manage malaria cases promptly.
“Malaria kills more people than HIV, tuberculosis, and measles combined. It is preventable and treatable, yet it remains a leading killer. Let us deal with malaria as seriously as we did with Covid-19 and other public health emergencies,” Dr Kitaka advises.
CRITICAL POLICY CHANGES
One of Uganda’s partners in the fight against malaria has been the United States International Aid Agency (USAID). USAID’s Uganda Health Supply Chain program helped some health facilities revitalise Medicine and Therapeutics Committees. USAID supported organisations such as the Malaria Consortium by providing technical and programmatic support to the government at central and local levels. It sought to increase the impact and reach of malaria prevention and diagnostic services and to strengthen the government’s capacity to design, plan, and monitor malaria control activities.
Unfortunately, US President Donald Trump’s administration is considering merging USAID into the State Department in a major revamp that would shrink its workforce and align its spending with Trump’s ‘America First’ policy. In a January 20 executive order announcing a 90-day pause in most foreign aid, Trump said the US “foreign aid industry and bureaucracy are not aligned with American interests and in many cases antithetical to American values.”
This will likely result in shortages of vaccines, essential medicines, and healthcare staffing in rural clinics, resulting in a resurgence of preventable diseases. The socioeconomic toll of malaria is profound. The disease accounts for 40 percent of school absenteeism and significant financial losses due to reduced productivity. However, the challenges the disease presents are not insurmountable. With sustained efforts, innovative strategies, and community cooperation, Uganda can reduce its malaria burden and save lives. Uganda has the tools and knowledge to succeed. The question, though, is whether the nation can muster the collective will to eradicate this ancient scourge once and for all.
