A total of 180,666 patients were treated at the outpatients department of the three facilities between 1st January 2019 and 28th February 2022. Most were female 118,815 (65.75%) and the median age of the patients was 16 (6–32) years. The average atmospheric temperature across the three study sites was 30.25 (± 5.49)˚C ranging from 30.8˚C to 32.5˚C. The average rainfall distribution at the sites was 140.4 (± 77.21) mm with the lowest 104.81mm and the highest 169.88mm. as shown in Table 1.
Table 1
Patient demographics and environmental characteristics stratified by site from January 2019 to February 2022.
| Lumino | Kasambya | Walukuba | All sites combined |
Median Age (IQR) | 17(5–31) | 16(6–32) | 15(7–33) | 16(6–32) |
Female (n%) Male (n%) | 42803(67.81%) 20319(32.19%) | 31189(64.34%) 17287(35.66%) | 44346(65.65%) 23204(34.35%) | 118815(65.75%) 61849(34.23%) |
Average temperature in˚C (SD) | 31.88(2.51) | 30.83(2.65) | 32.53(1.96) | 30.25(5.49) |
Average rainfall in mm (SD) | 169.88(101.29) | 104.81(52.35) | 146.61(89.24) | 140.43(77.21) |
Impact of the COVID-19 waves on outpatient malaria indicators.
OPD attendance (Overall impact).
There was neither change in level of OPD visits a month immediately on onset of the 2nd COVID-19 wave (β2 = -626.06, P > 0.05) nor change in trend of OPD visits during the 2nd COVID-19 wave duration (β3 = -192.89, P > 0.05). However, immediately on onset of the 3rd COVID-19 wave (during its 1st month), there was a significant increase in the OPD visits (β2= 1532.91, P = 0.03) but overtime there wasn’t significant change in trend of OPD visits during the 3rd COVID-19 wave ( β3 = -161.39, P > 0.05) as shown in Fig. 1 and Table 2. Overall (all sites combined), there was no significant difference between the observed versus expected total number of patients seen at the out-patient departments during the 2nd COVID-19 wave (14950 vs 20016; IRR = 0.75[0.29–1.20]) however, there was a 52% decline in the number of observed versus expected total number of patients seen at the out-patient departments during the 3rd COVID-19 wave duration (15101 vs 31154; IRR = 0.48[0.41–0.56]) as shown in Table 3.
Table 2
Change in level of the outcome and change in trend of the outcome on onset of the two interruptions
| 2nd COVID-19 wave onset (May 2021) | 3rd COVID-19 wave onset (November 2021) |
Change in level/β2 (P-value). | Change in trend/β3 (P-Value). | Change in level/β2 (P-value). | Change in trend/β3 (P-Value). |
OPD attendance | -626.06(0.22) | -192.89(0.13) | 1532.91(0.03) | -161.39(0.44) |
Proportion of suspected malaria cases | 0.37(0.86) | -0.25(0.55) | -4.51(0.09) | 2.55(0.01) |
Test positivity rate | -0.16(0.00) | 0.02(0.08) | -0.01(0.88) | -0.04(0.15) |
Proportion of suspected malaria cases tested | -3.84e-16(0.51) | 7.95e-18(0.96) | -4.11e-16(0.43) | -2.77e-16(0.41) |
Proportion of malaria cases treated | 3.33e-14(0.34) | 7.66e-16(0.95) | 5.31e-14(0.24) | 1.21e-14(0.60) |
Table 3
Estimated and observed outcomes (averages for proportion outcomes and totals for the count outcome) during the three interruption durations (ALL SITES COMBINED).
| 2nd COVID-19 wave duration (May-August 2021) | 3rd COVID-19 wave duration (November 2021-February 2022) |
| Observed | Predicted | Ratio(95% CI) | Observed | Predicted | Ratio(95% CI) |
OPD attendance | 14950 | 20016 | 0.75(0.29–1.20) | 15101 | 31154 | 0.48(0.41–0.56) |
Proportion of suspected malaria cases | 36.45% | 36.44% | 1.00(0.92–1.08) | 35.25% | 33.69% | 1.05(0.95–1.13) |
Test positivity rate | 35.30% | 33.89% | 1.04(0.74–1.34) | 40.16% | 36.28% | 1.11(0.90–1.31) |
Proportion of suspected malaria cases tested | 99.47% | 99.97% | 0.99(0.98-1.00) | 99.86% | 99.99% | 0.99(0.99–0.99) |
Proportion of malaria cases treated | 94.99% | 99.85% | 0.95(0.92–0.98) | 96.96% | 99.93% | 0.97(0.94-1.00) |
OPD attendance (site specific impact).
There wasn’t a significant difference between the observed versus predicted OPD visits at a Lumino HCIII for the 2 durations; 1) 2nd COVID-19 wave (5277 vs 4698; IRR = 1.12[0.86–1.39]) and 2) 3rd COVID-19 wave (5391 vs 5332; IRR = 1.01[0.96–1.06]) as shown in Table 4. However, there was a 37% decline (7849 vs 13931; IRR = 0.63[0.57–0.70]) and 59% decline (3832 vs 9297; IRR = 0.41[0.37–0.45]) in OPD visits during the 2nd COVID-19 wave duration and 3rd COVID-19 wave duration respectively at Kasambya HCIII as shown in Table 5. At Walukuba HCIV, there was a 46% decline (4770 vs 8768; IRR = 0.54[0.15–0.94]) in OPD visits during the 2nd COVID-19 wave and a 67% decline (4950 vs 15065; IRR = 0.33[0.23–0.43]) during the 3rd COVID-19 wave as shown in Table 6.
Table 4
ESTIMATED AND OBSERVED OUTCOMES (AVERAGES FOR PROPORTION OUTCOMES AND TOTALS FOR THE COUNT OUTCOME) DURING THE THREE INTERRUPTION DURATIONS ( high malaria transmission intensity site).
| 2nd COVID-19 wave duration (May-August 2021). | 3rd COVID-19 wave duration (November 2021-February 2022). |
Observed | Predicted | Ratio(95% CI) | Observed | Predicted | Ratio(95% CI) |
OPD attendance | 5277 | 4698 | 1.12(0.86–1.39) | 5391 | 5332 | 1.01(0.96–1.06) |
Proportion of suspected malaria cases | 78.24% | 79.08% | 0.99(0.97–1.01) | 82.53% | 78.45% | 1.05(0.99–1.01) |
Test positivity rate | 48.40% | 36.71% | 1.31(0.70–1.93) | 59.91% | 32.29% | 1.19(1.65–2.06) |
Proportion of suspected malaria cases tested | 99.34% | 99.93% | 0.99(0.98–1.01) | 100.00% | 100.00% | |
Proportion of malaria cases treated | 90.57% | 18.48% | 4.92(-6.85-16.69) | 95.02% | 0.24% | 397.28(-796.51-7811.09) |
Table 5
ESTIMATED AND OBSERVED OUTCOMES (AVERAGES FOR PROPORTION OUTCOMES AND TOTALS FOR THE COUNT OUTCOME) DURING THE THREE INTERRUPTION DURATIONS (MODERATE MALARIA TRANSMISSION INTENSITY SITE).
| 2nd COVID-19 wave duration (May-August 2021). | 3rd COVID-19 wave duration (November 2021-February 2022). |
Observed | Predicted | Ratio(95% CI) | Observed | Predicted | Ratio(95% CI) |
OPD attendance | 7849 | 13931 | 0.63(0.57–0.70) | 3832 | 9297 | 0.41(0.37–0.45) |
Proportion of suspected malaria cases | 60.12% | 75.87% | 0.79(0.32–1.26) | 60.79% | 76.28% | 0.79(0.72–0.87) |
Test positivity rate | 22.19% | 34.30% | 0.65(0.41–0.88) | 29.21% | 40.16% | 0.73(0.63–0.83) |
Proportion of suspected malaria cases tested | 97.59% | 99.72% | 0.99(0.61–1.39) | 99.79% | 99.97% | 0.99(0.99–0.99) |
Proportion of malaria cases treated | 90.57% | 18.40% | 4.92(-10.06-19.90) | 95.57% | 0.24% | 392.29(-5420.98-6215.56) |
Table 6
ESTIMATED AND OBSERVED OUTCOMES (AVERAGES FOR PROPORTION OUTCOMES AND TOTALS FOR THE COUNT OUTCOME) DURING THE THREE INTERRUPTION DURATIONS (LOW MALARIA TRANSMISSION INTENSITY SITE).
| 2nd COVID-19 wave duration (May-August 2021). | 3rd COVID-19 wave duration (November 2021-February 2022). |
Observed | Predicted | Ratio(95% CI) | Observed | Predicted | Ratio(95% CI) |
OPD attendance | 4770 | 8768 | 0.54(0.15–0.94) | 4950 | 15065 | 0.33(0.23–0.43 |
Proportion of suspected malaria cases | 41.12% | 34.99% | 1.18(0.48–1.87) | 30.76% | 14.54% | 2.12(2.07–2.16) |
Test positivity rate | 49.36% | 55.02% | 0.89(0.63–1.16) | 47.53% | 32.92% | 1.44(0.74–2.15) |
Proportion of suspected malaria cases (Overall impact).
On onset of the 2nd COVID-19 wave, there was neither an immediate significant change in the level (β2 = 0.37, P > 0.05) of the proportion of suspected malaria cases nor a significant change in trend (β3 = -0.25, P > 0.05) of the proportion of suspected malaria cases during the 2nd COVID-19 wave. There wasn’t a significant change in the level (β2 = -4.51, P > 0.05) of the proportion of suspected malaria cases on onset of the 3rd COVID-19 wave however, there was a significant change in trend (β3 = 2.55, P = 0.01) with an increment in the proportion of suspected malaria cases during the 3rd COVID-19 wave duration as shown in Fig. 2 and Table 2. Overall, there was no significant differences between the observed versus predicted mean proportion of suspected malaria cases during the 2nd COVID-19 wave duration (36.45% vs 36.44%; RPR = 1.00[0.92–1.08]). Likewise, there were no significant differences between the observed versus predicted mean proportion of suspected malaria during the 3rd COVID-19 wave (35.25% versus 33.69%; RPR = 1.05[0.95–1.13]) as shown in Table 3.
Proportion of suspected malaria cases (Site specific impact).
At Lumino HCIII, there wasn’t a significant difference between the observed versus predicted proportion of suspected malaria cases; 1) during the 2nd COVID-19 wave (78.24% versus 79.08%; RPR = 0.99[0.97–1.01]) and 2) during the 3rd COVID-19 wave (82.53% versus 78.45%; RPR = 1.05[0.99–1.01]) as shown in Table 4. At Kasambya HCIII, there was a 21% decline in the proportion of suspected malaria cases during the 3rd COVID-19 wave (60.79% versus 76.28%; RPR = 0.79[0.71–0.87]) however, during the 2nd COVID-19 wave duration, there was no significant difference between the observed versus predicted (60.12% versus 75.87%; RPR = 0.79[0.32–1.26]), proportion of suspected malaria cases at the moderate malaria transmission site as depicted in Table 5. At Walukuba HCIV, there were no significant differences between the observed versus the predicted proportion of suspected malaria cases tested during the 2nd COVID-19 wave duration (49.36% versus 55.02%; RPR = 0.89[0.63–1.16]). However, during the 3rd COVID-19 wave duration, the observed suspected malaria cases were significantly higher than expected (30.76% versus 14.54%; RPR = 2.12[2.07–2.16]).
Test Positivity rate (Overall impact).
On onset of the 2nd COVID-19 wave, there was an immediate significant decline (β2 = -0.16, P = 0.00) in the malaria TPR as depicted in Fig. 3 and Table 2. However, there wasn’t a significant change in trend (β3 = 0.02, P > 0.05) of the TPR during the entire 2nd COVID-19 wave duration. In the same way, there wasn’t a significant change in level (β2 = -0.01, P > 0.05) of the malaria TPR immediately on onset of the 3rd COVID-19 wave nor was there a significant change in trend (β3 = -0.04, P > 0.05) of the malaria TPR during the 3rd COVID-19 wave duration as shown in Table 2. Overall, there was no significant difference between the observed versus expected malaria TPR (all sites of varying malaria transmission intensities combined) during the 2nd COVID-19 wave (35.30% vs 33.89%; RPR = 1.04[0.74–1.34]) and during the 3rd COVID-19 wave (40.16% vs 36.28%; RPR = 1.11[0.90–1.31]) as shown in Table 3.
Test Positivity rate (Site specific impact).
At Lumino HCIII, there was no significant difference between the observed versus the predicted malaria TPR during the 2nd COVID-19 wave duration (48.40% vs 36.71%; RPR = 1.31[0.70–1.93]). However, during the 3rd COVID-19 wave, the observed TPR was significantly higher (59.91% vs 32.29%; RPR = 1.19[1.65–2.06]) than expected as shown in Table 4. At Kasambya HCIII, there was a 35% decline and 27% decline in the malaria TPR during the 2nd COVID-19 wave and 3rd COVID-19 wave duration respectively at this site as shown in Table 5. At Walukuba HCIV, there was no significant difference between the observed versus predicted malaria TPR for the three durations; 1) during the 2nd COVID-19 wave duration (49.36% vs 55.02%; RPR = 0.89[0.63–1.16]), 2) and during the 3rd COVID-19 wave duration (47.53% vs 32.92%; RPR = 1.44[0.74–2.15]) as shown in Table 6.
Impact of the COVID-19 waves on the proportion of suspected malaria cases tested.
Overall impact
On onset of the 2nd COVID-19 wave, there was neither an immediate change in level (β2 = -3.84 e-16, P > 0.05) of the proportion of suspected malaria cases tested nor a significant change in trend (β3 = -7.95e-18, P > 0.05) of the proportion of the suspected malaria cases tested during the 2nd COVID-19 wave duration. There was neither a significant change in the level (β2 = -4.11e-16, P > 0.05) of the proportion of suspected malaria cases tested on onset of the 3rd COVID-19 wave nor a significant change in the trend (β3 = -2.77e-16, P > 0.05) of the proportion of suspected malaria cases tested during the 3rd COVID-19 wave duration as shown in Fig. 4 and Table 2. Overall, there was both a 1% decline in the proportion of suspected malaria cases tested during the 3rd COVID-19 wave duration (99.86% vs 99.99%; RPR = 0.99[0.99–0.99]). However, there was no significant difference between the observed versus predicted mean proportion of tested malaria during the 2nd COVID-19 wave (99.47% vs 99.97%; RPR = 0.99[0.98-1.00]) as shown in Table 3.
Site specific impact.
At Lumino HCIII, there were no significant differences between the observed versus predicted proportion of suspected malaria cases tested during the all the two interruption durations as shown in Table 4. Likewise, there wasn’t significant differences between the observed versus predicted proportion of suspected malaria cases tested at Kasambya HCIII during the 2nd COVID-19 wave however, during the 3rd COVID-19 wave duration, there was a 1% decline in the proportion of suspected malaria cases tested (99.79% vs 99.97%; RPR = 0.99[0.99–0.99]) as shown in Table 5.
Impact of the COVID-19 waves the proportion of malaria cases prescribed artemether lumefantrine (AL).
Overall impact.
On onset of the 2nd COVID-19 wave, there wasn’t an immediate significant change in level (β2 = 3.33 e-14, P > 0.05) of confirmed cases prescribed AL nor was there a significant change in trend (β3 = 7.66 e-16, P > 0.05) of the proportion of malaria cases prescribed AL. There wasn’t an immediate significant change in level (β2 = 5.31 e-14, P > 0.05) of the proportion of malaria cases prescribed AL on onset of the 3rd COVID-19 wave nor a significant change in trend of the proportion of malaria cases prescribed AL during the 3rd COVID-19 wave duration (β3 = 1.21 e-14, P > 0.05) as shown in Fig. 5 and Table 2. Overall, there was a 5% decline (94.99% vs 99.85%; RPR = 0.95[0.92–0.98]) in the proportion of malaria cases treated during the 2nd COVID-19 wave and a no significant difference between the observed versus predicted proportion of malaria cases prescribed AL during the 3rd COVID-19 wave (96.96% vs 99.93%; RPR = 0.97[0.94-1.00]).
Site specific impact.
At Lumino HCIII, during the 2nd (90.57% vs 18.40%; RPR = 4.92[-6.85-16.69]), and 3rd (95.02% vs 0.24%; RPR = 397.28[-796.51-7811.09]) COVID-19 waves, there was no significant differences between the observed versus expected proportion of malaria cases prescribed AL. At Kasambya HCIII, there were no significant differences between the observed versus expected proportion of malaria cases treated for the 2nd (90.57% vs 18.40%; RPR = 4.92[-10.06-19.90]) and 3rd (95.57% vs 0.24%; RPR = 392.29[-5470.98-6215.56]) COVID-19 wave durations.