Unusual malaria hits northern Uganda

By Ronald Musoke and Flavia Nassaka

Doctors say worst affected are children born in the last three years

At the moment, the children’s ward is one of the busiest at St. Mary’s Hospital, Lacor, in Gulu district of northern Uganda. Almost every baby has a pistol-like needle plastered on their tiny wrist while a few others have tubes running into their little noses. That is where the drugs are pumped into their tiny bodies.

The babies’ shrieks— one after another— pierce the otherwise early afternoon calm of this missionary-founded hospital located about 5km north of Gulu town.

Save for the odd father sandwiched in a queue of 15 mothers who are ready to receive anti-malarial drugs, the majority of the mothers are carrying babies on their backs and shoulders while others are holding them in their laps seated on the floor. Eric Kidega, a lean and youthful doctor is examining a girl, about 5-years old who had a badly swollen face.

The rest remain calm as they wait patiently to be attended to by the doctors. The situation seems desperate.

Dr.  Cyprian Opira, the executive director, Lacor Hospital, says the hospital has been registering a rapid increase in the number of malaria cases. But he has also been noticing something unusual.

Opira says some of the patients—the majority of whom are babies— seem to have low immunity as most of them are brought having severe malaria. He says when an individual keeps getting malaria; they are more likely to develop immunity for the disease. But someone who lacks immunity normally comes to hospital with severe malaria similar to someone who has come from Europe. After seeing several such cases, Opira says, most were born over the last three years when the government started the Indoor Residual Spraying (IRS) programme against malaria.

Opira adds that halting the IRS project is to blame for the resurgence of malaria.

“The reduction in malaria cases was obviously quite related to the beginning of the IRS and the increase is also associated with the stopping of the IRS.

“We think that the IRS had a big impact on the reduction of malaria incidence in the Acholi sub-region.

Opira says the number of malaria cases had reduced drastically until the IRS was stopped in October 2014. When the next rain season started in mid-April 2015, malaria cases started going up – slightly at first; from 30 to 130 cases recorded at the hospital until they hit 500 by July 25 when The Independent visited.

A few days earlier, the Ministry of Health had issued a report showing that Gulu was the most malaria-hit district in Uganda. Gulu, which is known as the epicenter of Uganda’s worst Ebola hemorrhagic fever outbreak, was now the epicenter of the resurgence of malaria in northern Uganda. The epidemic is exerting pressure on the drug stock, health workers, health facilities which are struggling to accommodate the patients.By July 23, according to Ministry of Health statistics, up to 162 deaths had been recorded in health facilities and the community in 10 districts of Northern Uganda since May when the numbers of Malaria patients started increasing. Among other highly affected districts (beneficiaries of IRS) include Apac with 3278 cases, Amuru 2249, Kitgum with 5382 cases and Oyam with 2219 cases bringing the total number of cases to 22873. Although the National Medical Stores (NMS) responded well by restocking the anti-malaria drugs, the demand remains high and drug stocks run out fast.

In Nwoya District, Franco Olabo, the deputy Chief Administrative Officer, is equally perturbed by the rapid rise in malaria incidents. Olabo says malaria cases are the majority at Anaka Hospital which is the biggest health facility in the district which borders Gulu to the Southwest.

But he also admits that everyone in the Acholi sub-region seems to be grappling in the dark for answers. Olabo told The Independent that Nwoya benefitted from the IRS project between 2012 and 2013 and after the spray, malaria cases dropped significantly.

Although The Independent was not in position to get the actual picture at the Gulu Regional Referral Hospital, Andrew Moses Awany, the Gulu Resident District Commissioner said in an interview on July 24 that the sudden rise in cases of people testing positive for malaria started in May, which coincided with the rainy season. However, Awany also noted that this was not the case two years ago.

He said there have always been severe malaria cases in the two sub-regions (Acholi and Lango) but when mosquitoes were wiped out, malaria cases dropped, especially those presenting with severe anemia. He says the absence of mosquitoes under the IRS initiative played a hand in a reduction of people’s immunity.

In Gulu District, Awany says, the number of people suffering from malaria rose from an average of 40 cases per day in May to 100 per day per health facility in July. Most were reported to Health Centre IIIs, IVs up to the referral hospital.

“As we talk now,” Awany told The Independent in July, “over 1200 cases of people are testing positive for malaria per week.”Awany also partly blames the IRS programme which stopped in November, 2014. He says when the IRS project was implemented in the district between 2013 and 2014, there was a marked reduction in the number of mosquitoes and malaria cases by almost 50%.

False hope

When IRS was initiated in 2008 amidst wide criticism, the Ministry of Health assured the public that with the spraying, malaria was bound to be kicked out of Uganda since, the Dichloro-diphenyl-trichloroethane (DDT), a synthetic chemical used in IRS was particularly good at killing insects and that it would take many years for mosquitoes to breed again. People in northern Uganda were, therefore, surprised when malaria made a comeback barely a year after the spraying ceased.

When The Independent asked Dr. Albert Okui, the Manager of the Malaria Control Programme at the Health ministry about this, he said the DDT can only offer protection within six months; after that the vector will breed again.

He said government stopped spraying these districts in October 2014 and moved to 14 new districts which were considered to have a higher prevalence of malaria. At that time, Okui says, Malaria prevalence in the districts was just 7% from 60% in 2008.

Since the spraying stopped and malaria cases increased, the districts have increased sensitisation on preventive mechanisms as the only sustainable solution. The IRS project worked very well but it was very expensive. Okui told The Independent that they cannot afford to spray sustainably since it requires up to Shs1.2 billion shillings to spray a small district yet for efficacy they require two rounds of spraying per year.

The preventive measures advocated include use of mosquito-treated nets and giving intermittent presumptive therapy like giving the anti-malaria drug Fansidar (Sulfadoxine/pyrimethamine) to pregnant mothers as part of antenatal care.

The local authorities are also talking to the communities to clear bushes around their homesteads and drain water-logged areas to stop mosquitoes from breeding within their homesteads. The Acholi-Lango region is a vast land with lash green bushes and marshland. This environment is such an excellent ground for mosquito breeding.

Awany says that as the fight against malaria goes on, the authorities are also grappling with challenges in mobilising the communities. He explains that many organisations have donated thousands of mosquito-treated nets to people who go to health facilities but some end up using these nets for other purposes like trapping white ants while others use them as ropes for tethering their goats.

Others, he says, use them for fishing. A number of outreach programmes have been done but communities do not seem to realise the need to take up the health caution that the Village Health Teams (VHT) give to them. Going forward, Gulu intends to come up with an ordinance to respond to malaria. The law will not only go out to catch people who are found misusing mosquito-treated nets but those who keep bushy places and water logged surfaces near their homes will be taken to court to face the law so that upon conviction, they are punished.

“People must not leave the government to do the donkey work when they are doing nothing,” he says, “As people who deserve to live healthy lives, they must take responsibility over their lives.” The RDC says the ordinance will become an active law before the end of this year.

The IRS programme was not popular in the beginning and not everybody had their houses sprayed. The decampaigning by civil society demobilized the minds of the local people, Awany says.

But it is also important to understand the nature of houses the people in the sub-region live in. Most of the people live in semi-permanent houses.

These are mainly grass-thatched houses built with mud and cow dung.  They will smear these houses occasionally and it is possible the drug which would have been sprayed would wear out in a short time.

But also these houses are easy to demolish and build new ones. The case would possibly have been different if the IRS project was implemented within a community with more permanent houses where the drug is able to last a little long.

Awany told The Independent that people must be in position to look at the preventive mechanism as the best way to fight malaria.

“If you have a mosquito-treated net and you sleep under it; in the evening you close the windows, you can be in position to reduce the cost.”

New Interventions

Dr. Asuman Lukwago, the Ministry of Health Permanent Secretary says since Uganda cannot afford sustainable use of IRS, they are proposing a cheaper option. He told The Independent that the Ministry is in talks with the Japanese International Cooperation Agency to see whether they can import an insecticide from Japan. He said the insecticide which is already widely used in Europe during summer will first be tested for efficacy before it is recommended for general use.He said the insectide will be cheaper and available for people to buy other than using big solutions like IRS which can only be afforded by government.

But, Ellady Muyambi of the Uganda Network on Toxic Free Malaria Control (UNETMAC) says Uganda’s first attempt to use DDT for spray was also wrong. He says there are alternatives to chemical approaches to deal with this disease as already demonstrated by examples from Kenya, Ethiopia, Mexico and Vietnam where DDT is not used.

Muyambi maintains that although the decision to reintroduce IRS was made, there was limited technical knowledge of safe handling during IRS in the country. Besides, there was also inadequate capacity for safe use and effective monitoring of IRS operations. With such an environment, Muyambi says the results were bound not to be sustainable.

However, all the officials The Independent talked to in northern Uganda seemed to agree on one thing: authorities need to carry out research to find out what the real cause of the resurgence of malaria could be, apart from what the ministry is saying.