Prime
Drug-resistant malaria plants roots in Uganda
Patients at Rubare Health Centre IV in Ntungamo District in January. Uganda is facing an emergence of resistance to the most commonly used malaria medicines. Photo/File
What you need to know:
- Uganda has the highest malaria incidence rate globally.
Along with 13 health centre IIIs and four health centre IIs, Pallisa Hospital appears to be swimming against the tide. The 100-bed hospital set up in 1969 has since March 2021 been flooded with patients stricken with severe malaria. Most of them are children aged between five and 15.
“The severe malaria is characterised by urinating blood that eventually leads to anaemia; thus requiring blood transfusion, which blood is also scarce,” Dr Godfrey Mulekwa, Pallisa’s District Health Officer (DHO), told this newspaper in March.
Back then, the hospital, which has 181 people on its payroll, was grappling with a drug stock-out that first reared its ugly head in October 2022.
Dr Mulekwa further revealed that even before the stock-out, anti-malaria drugs were powerless at preventing recurrences of malaria.
For Pallisa Hospital, which serves patients from Kibuku, Butebo, Bukedea, and Kaliro, the influx of patients was particularly overwhelming.
Trail of destruction
A new study has now offered some answers as to why Uganda is facing an emergence of resistance to the most commonly used malaria medicines.
Uganda holds the unfortunate distinction of having the highest malaria incidence rate globally, according to the World Health Organisation (WHO), with 478 cases per 1,000 population per year.
The intermittent and remittent fever stands as the primary cause of illness and mortality in Uganda, accounting for as much as 40 percent of all outpatient visits, 25 percent of hospital admissions, and 14 percent of all hospital fatalities.
The estimated malaria death toll in Uganda ranges between 70,000 and 100,000 deaths per year, surpassing the mortality rate of HIV/Aids.
The development also dents the country’s prospects of eliminate malaria entirely by 2030.
Data from Uganda, according to the scientists in the study titled “Evolution of Partial Resistance to Artemisinins in Malaria Parasites in Uganda,” showed the emergence of partial resistance to Artemisinins in multiple geographic locations. It especially spotlighted increasing prevalence and regional spread over time.
Partial resistance to artemisinin means there is a delay in malaria parasite clearance after treatment with Artemisinin-based combination therapy (ACT).
Artemisinin-based combination therapies are the standard treatments for malaria in Uganda and much of the African continent. According to WHO, antimalarial drug resistance, in particular resistance to Plasmodium falciparum, challenges the treatment and control of malaria.
Resistance occurs when microorganisms, such as bacteria, viruses, fungi, and parasites, become resistant to drugs, making infections more challenging to treat and causing the disease to spread, leading to severe illness and death.
The WHO has previously warned that the emergence of resistance to artemisinin-based combination therapies in Africa would have devastating consequences. It added that continued surveillance for the emergence of resistance on this continent is a high priority.
The study
The researchers, according to findings published in The New England Journal of Medicine and Lancet, performed annual surveillance among patients who presented with uncomplicated malaria at 10 to 16 sites across the country from 2016 through 2022.
Study clinics were set up in the districts of Jinja, Tororo, Kapchorwa, Katakwi, Amolatar, Kole, Agago, Kaabong, Lamwo, Koboko, Arua, Hoima, Mubende, Kasese, Kanungu, and Rukiga. Of these, only Katawki received four rounds of indoor residual spraying (IRS) of insecticides every eight months from 2016 through 2018.
Amolatar and Tororo received regular IRS beginning in 2015. Lamwo, Agago, and Kole received IRS every six months from 2010 through 2014 and once in 2017. The other districts—Kanungu, Rukiga, Kasese, Mubende, Jinja, Kapchorwa, Hoima, Arua, and Koboko—did not receive IRS.
“By 2021 to 2022, the prevalence of parasites with validated or candidate resistance markers reached more than 20 percent in 11 of the 16 districts where surveillance was conducted,” the peer-reviewed body of work states, adding, “The PfK13 469Y and 675V mutations were seen in far northern Uganda in 2016-2017 and increased and spread thereafter, reaching a combined prevalence of 10 to 54 percent across much of northern Uganda, with spread to other regions.”
They add: “The 469F mutation reached a prevalence of 38 to 40 percent in one district in southwestern Uganda in 2021-2022. The 561H mutation, previously described in Rwanda, was first seen in southwestern Uganda in 2021, reaching a prevalence of 23 percent by 2022. The 441L mutation reached a prevalence of 12 to 23 percent in three districts in western Uganda in 2022. Genetic analysis indicated local emergence of mutant parasites independent of those in Southeast Asia.”
The researchers explain that emergence of resistance was observed predominantly in areas where effective malaria control had been discontinued or transmission was unstable.
Previous research
A 2020 study titled “Changing Prevalence of Potential Mediators of Aminoquinoline, Antifolate, and Artemisinin Resistance Across Uganda” whose body of work was carried in The Journal of Infectious Diseases spotlighted the waning power of Artemisinin-based combination therapy (ACT).
“With more recent replacement of chloroquine with ACTs to treat malaria across Africa, loss of the PfCRT 76T and PfMDR1 86Y and 1246Y mutations has been documented in many countries, including Uganda, where prevalence of parasites with the PfCRT 76T allele decreased markedly over the last decade,” the study noted, adding that the “mutant parasites have persisted in Uganda over a decade after replacement of chloroquine.”
Govt speaks out
Dr Jimmy Opigo, the manager of the Malaria Programme at the Health ministry, was unavailable for a comment by press time.
The Health Minister, Dr Jane Aceng, however, confirmed in February a rise in cases of malaria drug resistance in the country, including the likes of Primaquine and Coartem, which are widely used in the country.
Mosquitoes, the minister added, have become resistant to chemicals used in nets and indoor spraying, with Uganda seeing an upsurge of malaria-related deaths especially in West Nile, Lango, Acholi, Karamoja, Bukedea and Busoga sub-regions.
The minister said Uganda had instituted a scientific advisory committee to follow up on the issue of drug resistance results of which would contribute to policy changes in malaria treatment in the country.
Additional reporting by Mudangha Kolyangha
