EFFECTS OF INTEGRATED COMMUNITY CASE MANAGEMENT ON MALARIA TEST POSITIVITY RATES IN CHILDREN UNDER-FIVE IN NORTHERN UGANDA

Abstract

Introduction Over 216 million Malaria cases and 445,000 Malaria deaths globally were reported in 2015 according to the 2016 World malaria report. Despite the reduction in mortality of about 1000 deaths between 2010 and 2015, malaria is still of big public health concern especially in sub Saharan Africa. Uganda ranks 9th among the high malaria burden countries according to the 2016 World malaria report. The Uganda Demographic Health Survey 2016 indicates the prevalence of Malaria among children below the age of five years at approximately 12 cases per 1000 population in urban areas while in rural areas at 35 cases per 1000 population. Between 2000 and 2015, Uganda reduced the Malaria burden from 43% to 19% and this progress in malaria reduction is largely attributed to the scale up of malaria control interventions. These interventions include indoor residual spraying, nationwide distribution of long lasting insecticide treated nets and integrated community case management among others. Uganda introduced integrated community case management (iCCM) in 2010 and this programme is supported by a number of implementing partners in currently 71 districts. Objective The main objective of this study was to assess the effect of integrated community case management on malaria Test Positivity Rates in children under five years and to further examine the factors that influence its implementation in northern Uganda. Methods This was a retrospective cross sectional review of data collected at public health facilities in Northern Uganda. The malaria test positivity rates (TPR) of children under the age of five years presenting to facilities between July 2015 and December 2017 was compared in health facilities of districts that had rolled out iCCM to those that had not rolled out iCCM using health facility monthly data that was submitted to the DHIS2. . In addition, qualitative data to understand the facilitators and barriers to implementation of iCCM was collected using key informant interviews with iCCM focal persons from Ministry of Health (MoH) and implementing partners. Ethical approval to conduct this study was obtained from local and national ethical boards. Results Malaria TPR at heath facilities was significantly associated with roll out of iCCM in the districts where the health facility was located. Introduction of iCCM was observed to be associated with a 12% reduction in TPR. (Margin -0.121 at 95% CI: -0.14, -0.10) In addition, IRS and LLIN implementation were also associated with reductions in TPR. IRS resulted in a 3% reduction (Margin-0.030 95% CI-0.06, 0.00) in reported TPR while LLIN implementation resulted in a 2% reduction in reported TPR (Margin -0.016 95% CI-0.03, -0.01)). Conclusions This study shows that implementation of iCCM is associated with a reduction in test positivity rates in children under five years even in the presence of other interventions (IRS and LLINs). Overall the performance of iCCM was good, however continued advocacy is needed for iCCM in combination with other interventions as we move to control and eventually elimination of Malaria. We recommend that iCCM should further be scaled up especially in northern Uganda where the burden of Malaria is still very high with continued use of a combination of IRS, LLIN and iCCM in areas with high burden of Malaria.