In 2018, the SURMa project, in collaboration with Uganda’s National Malaria Control Division (NMCD) and the Nwoya DHT, revised the malaria surveillance system and set up a district-led surveillance system. An independent DMSRT was created to manage and implement this surveillance system. The DMSRT was comprised of technical personnel, according to Uganda’s Guidelines for Preparedness and Response for Malaria Epidemics (13) e.g. environmental health officer, clinician, laboratory technician, Nurses, biostatistician, health educator, a logistician, and public, private and community health workers.
The DMSRT conducted a rapid assessment to map out specific geographic areas most affected by malaria and as result the two sub-counties namely Alero and Anaka (Fig. 2), where this study was conducted were identified. This was based on the DHIS2 data, which allows for data extraction at health facility level,
In addition, a multi-sectoral management taskforce was also formed which includes key district sector leads from health, education, engineering, and community development, as well as implementing partners to oversee and support the DMSRT. The SURMa project supported the training of the DMSRT, equipped all health facilities (public and private) with malaria normal channel graphs and supplied reporting tools to the VHTs.
Health Facility (HF) record reviews and mapping exercises were conducted and the specific villages within these sub-counties most impacted were identified for targeted interventions. The mapping exercise involved, using the HF data on malaria cases to identify the villages within the catchment area of the HFs with the highest malaria cases. This was followed by conducting micro census to determine the total population as well as the number of vulnerable groups such as children under 5 years and pregnant women residing in these village; identifying the available community resources such as VHTs and local leaders to mobilise people for the test and treat campaigns. A field visit was carried out to the respective sub-counties to assess the awareness of the outbreak among the community and the availability of artemisinin-based combination therapy (ACT) and rapid diagnostic tests (RDTs) at the HFs and VHTs. The Nwoya district vector control officer did preliminary entomological surveillance, which was comprised of mosquito collection using spray catches and CDC light traps, in some villages and noted increased mosquito densities. A planning meeting was convened by the DHT to inform all relevant stakeholders of the rapid assessment findings, mobilise resources and develop a comprehensive district response plan, based on the findings and guided by policy.
Key interventions, categorised as immediate, intermediate and long-term were designed, agreed on by key stakeholders and approved by the MoH. The expected outcome of the immediate intervention was to avert deaths through the testing and treatment of all cases; the intermediate objective was to bring down the upsurge, while the long-term goal was to sustain the gains achieved.
Using the CDC field epidemiological training manual, all, in-charges and the staff in charge of records at health facilities from the two sub-counties were (both public and private) were trained and provided with malaria surveillance tools, such as weekly malaria normal channel graphs. The remaining health workers from these facilities and VHTs were trained and provided with tools and facilitation to conduct regular targeted Test, Treat and Track outreach activities in the most affected areas as part of surveillance response system. All VHTs in Alero and Anaka sub-counties were trained on malaria epidemic response and provide with reporting tools and more mRTs to conduct testing during home visits in their villages as part of malaria surveillance response. During home visits and test and treat outreaches, VHTs and health workers would also identify pregnant women and mobilise them to attend antenatal care (ANC) and receive intermittent preventive treatment in pregnancy (IPTp) for malaria.
The HFs conducted test (using RDTs), treat and track outreach activities, as per the national malaria control plan (1), in areas where out-patient department (OPD) records indicated high malaria cases. Of the 7,634 persons tested during these outreaches, 5,355 (70 percent) were positive for malaria and were given ACTs, as per the national guidelines. Malaria outreach activities were also integrated into other existing healthcare activities such as the Expanded Program of Immunization (EPI), HIV/AIDS outreach, etc. There was no reactive case detection component to the response, however, a total of 10 test and treat outreach activities were conducted in catchment areas/villages from five health facilities with high malaria caseloads. These outreach activities were conducted by staff from the public HFs, with support from the various implementing partners operating in Nwoya District.
To ensure and sustain adequate stock of key malaria commodities (ACTs, RDTs, sulfadoxine-pyrimethamine (SP) for IPTp) at the facilities and for the VHTs in the targeted sub-counties, regular monthly stock taking were conducted by the DMSRT in case of pending stock outs, key actions were made. These actions included the redistribution of commodities from health facilities to the VHTs for iCCM as well as from the neighbouring districts that had overstocks of these commodities to replenish the HF stock. This was done as part of surveillance response to ensure no stock out of commodities and was primarily conducted in the two sub-counties (Alero and Anaka).
Social behaviour change communication (SBCC) played a key role in the response against the malaria upsurge in Nwoya district. More than 3,400 SBCC materials were distributed through places of worship, schools, health facilities, community dialogue meetings, and VHTs. These materials were comprised of 22 key family health practice talking points, on a two-page flyer. Additionally, a total of 12 weekly radio talk shows and over 200 radio announcements/jingles were conducted during the response. The messages focused on the importance of consistent use of LLINs and seeking immediate medical attention in case one felt feverish or unwell. The HFs also conducted a total of eight malaria outreach activities during community sensitizations that focused on mass testing and treatment of malaria positive cases and promotion of malaria prevention and control best practices.
Ethical Considerations
This assessment was focused on electronic data in DHIS2. The investigation was determined to be non-human subject research according to Uganda’s research guidelines (14). Authorization of the study was obtained from the District Health Officer (DHO). The Health facility staff who participated in data use in preparation of the malaria normal channel were provided with information that their participation was voluntary and the activity was meant to build their capacity in malaria epidemic detection and their refusal would not lead to any consequences.