Impact of COVID-19 on routine malaria indicators in rural Uganda: an interrupted time series analysis

Jane F Namuganga,Jessica Briggs,Emmanuel Arinaitwe,Yasin Kisambira,James A Kapisi,Moses R Kamya,Jaffer Okiring,Sarah G Staedke,Chris Ebong,Michelle E Roh,Isaac Ssewanyana,Catherine Maiteki-Ssebuguzi,Grant Dorsey,Joaniter I Nankabirwa,Asadu Sserwanga

doi:10.1186/s12936-021-04018-0

Abstract

BackgroundIn March 2020, the government of Uganda implemented a strict lockdown policy in response to the COVID-19 pandemic. Interrupted time series analysis (ITSA) was performed to assess whether major changes in outpatient attendance, malaria burden, and case management occurred after the onset of the COVID-19 epidemic in rural Uganda.MethodsIndividual level data from all outpatient visits collected from April 2017 to March 2021 at 17 facilities were analysed. Outcomes included total outpatient visits, malaria cases, non-malarial visits, proportion of patients with suspected malaria, proportion of patients tested using rapid diagnostic tests (RDTs), and proportion of malaria cases prescribed artemether-lumefantrine (AL). Poisson regression with generalized estimating equations and fractional regression was used to model count and proportion outcomes, respectively. Pre-COVID trends (April 2017-March 2020) were used to predict the’expected’ trend in the absence of COVID-19 introduction. Effects of COVID-19 were estimated over two six-month COVID-19 time periods (April 2020-September 2020 and October 2020–March 2021) by dividing observed values by expected values, and expressed as ratios.ResultsA total of 1,442,737 outpatient visits were recorded. Malaria was suspected in 55.3% of visits and 98.8% of these had a malaria diagnostic test performed. ITSA showed no differences between observed and expected total outpatient visits, malaria cases, non-malarial visits, or proportion of visits with suspected malaria after COVID-19 onset. However, in the second six months of the COVID-19 time period, there was a smaller mean proportion of patients tested with RDTs compared to expected (relative prevalence ratio (RPR) = 0.87, CI (0.78–0.97)) and a smaller mean proportion of malaria cases prescribed AL (RPR = 0.94, CI (0.90–0.99)).ConclusionsIn the first year after the COVID-19 pandemic arrived in Uganda, there were no major effects on malaria disease burden and indicators of case management at these 17 rural health facilities, except for a modest decrease in the proportion of RDTs used for malaria diagnosis and the mean proportion of malaria cases prescribed AL in the second half of the COVID-19 pandemic year. Continued surveillance will be essential to monitor for changes in trends in malaria indicators so that Uganda can quickly and flexibly respond to challenges imposed by COVID-19.

Highlights

In March 2020, the government of Uganda implemented a strict lockdown policy in response to the Corona virus disease (COVID)-19 pandemic
While successes have been registered in malaria control in the country in the last decade, including increased coverage of control interventions and reductions in the overall disease burden [6, 7], there is concern that these achievements may be reversed by the global COVID-19 pandemic
Malaria Reference Centres (MRCs) were first established in 2006 by the Uganda Malaria Surveillance Project (UMSP), a project led by Makerere University, University of California, San Francisco (UCSF), and Infectious Diseases Research Collaboration (IDRC) groups, in collaboration with the Uganda Ministry of Health

Summary

Introduction

In March 2020, the government of Uganda implemented a strict lockdown policy in response to the COVID-19 pandemic. When the country registered its first confirmed case on 21st March 2020, additional restrictions were implemented, including: (1) closure of borders except for cargo and goods on 21 March, 2020; (2) suspension of public transport and restrictions on movement of private vehicle on 25 March, 2020; (3) mandatory testing of truck drivers on 10 April, 2021; (4) a national lockdown and curfew from 19.00 to 06.30 on 30 March, 2020, initially for 14 days but eventually extended to 26 May, 2020, and (5) closure of all schools [8] Despite these measures, Uganda’s COVID19 cases progressively increased over the period with the country registering its first 100 confirmed cases on 6 May, 2020, first death on 23 July, 2020, first 1000 cases on 9 June, 2020 and first wave peak in December 2020

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