Saving lives through scaling up severe malaria treatment in Uganda
On World Malaria Day, when the ambitious goal of eliminating malaria is within reach for several countries, it is important to remember that in many nations malaria continues to be a daily threat and one of the biggest killers of children. In Uganda, malaria accounts for 43 percent of hospital-based under-five deaths, and the entire country is at risk of the disease all year round. There are over 16 million cases each year among a population of 37 million people.
The recommended strategy for managing the disease is ensuring that all fevers are promptly tested for malaria and, if found positive, treated immediately with quality-assured artemisinin combination therapies. However, in a country with limited health system resources, routinely implementing this strategy is often a challenge. Many cases of malaria are left untreated and subsequently progress to severe malaria, which results in near certain death if unaddressed, particularly in vulnerable populations like children and pregnant women.
For decades, intravenous quinine was the recommended treatment for severe malaria, but it sometimes resulted in side effects like hypoglycemia (low blood sugar) and it was difficult to administer. However, the release of the World Health Organization’s (WHO) revised malaria treatment guidelines in 2011 provided a new recommendation to treat severe malaria with artesunate, a medication with higher efficacy, fewer side effects, and easier administration directly into the vein. In support of this policy change, CHAI worked with the government of Uganda to revise their treatment guidelines and adopt the use of injectable artesunate.
The shift to injectable artesunate in Uganda was further bolstered in 2013, when Medicines for Malaria Venture (MMV), Malaria Consortium, and CHAI partnered on a project funded by UNITAID that aimed to increase access to the medication and lower mortality in children in highly endemic countries. Through the project, over 1.5 million doses of lifesaving injectable artesunate were donated to Uganda, and over 3,500 health workers were trained on how to administer the drug.This effort helped treat thousands of children suffering from severe malaria, resulting in a marked reduction in deaths. My interactions with health workers revealed a clear positive impact, with several noting the ease of administration of injectable artesunate and the rapid recovery they now see in their patients.
In 2015, Uganda experienced a significant resurgence of malaria in the northern part of the country, but fortunately, mortality was limited due to the increased use of injectable artesunate. A District Health Officer in Pader District, which experienced a substantial increase in cases, noted that, “thanks to the availability of injectable artesunate, we registered few deaths at the peak of malaria epidemics because the drug was available, quick acting, and easy to administer. We were able to save lives of critically ill children.”
I had the opportunity to witness this myself with the treatment of Reagan, a young child from the Apac district of Uganda, who was treated for severe malaria. Reagan’s story, highlighted in a documentary video by MMV, shows the effectiveness of injectable artesunate but also demonstrates the need for comprehensive clinical care due to the many complications that can be associated with severe malaria, such as anemia.
This project and the government’s commitment to malaria reduction have facilitated a greater than 40 percent decrease in malaria incidence and mortality between 2010 and 2015. Uganda was recognized for this achievement at the 28th African Union Summit in Addis Ababa in February 2017, where the President of Uganda received an African Leaders Malaria Alliance Award for Excellence.
Despite these achievements, health system challenges remain in Uganda. Children who live far from health facilities can still die during the time it takes to travel from their community to a facility with capacity to provide injectable artesunate. In these cases, the WHO recommends the use of rectal artesunate until the child can get to the facility, though access to this medication has been limited. To address this gap, CHAI, UNICEF, and Swiss Tropical and Public Health Institute will partner on a three-year project funded by UNITAID that aims to generate evidence on the use of rectal artesunate to inform national scale up and further reduce child mortality from malaria.