Comprehensive Integrated Management Strategies for Malaria and COVID-19 Pandemic in Uganda

1. Background

Globally, malaria and COVID-19 remain a public health emergency of international concern (PHEIC) in Africa and affects any age and sex [1,2]. The emerging of coronavirus disease 2019 (COVID-19) pandemic may have negatively impacted malaria control[3,4,5]. The COVID-19 is caused by severe acute respiratory syndrome coronavirus - 2 (SARS-CoV-2)[6]. Management of malaria during the COVID-19 pandemic in Uganda required a comprehensive approach that balanced the need for both malaria and COVID-19 treatment, prevention and control[7,8]. In response to COVID-19 pandemic, Uganda government enforced several lockdowns over a period of 2 years[9]. Based on the COVID-19, Uganda ministry of health (MOH) adopted guidelines for management of both diseases in the country[10,11]. Prevention and control strategies are key to controlling and subsequently eliminating malaria and COVID-19 pandemic in Uganda[12,13]. However, COVID-19 strained the health system and disrupted malaria control efforts, raising concerns about potential upsurges in malaria cases and deaths[7]. These negatively impacted on economy and healthcare services in the country[14,15]. So far the pandemic severely damaged the world’s most developed countries like in similar settings[16]. There have been renewed interest on malaria with recent calls for its elimination[17]. The global tally of malaria cases reached 247 million in 2021 compared to 249 million case in 2022 and 263 million malaria cases in 2023; corresponding to a continued rise of malaria cases between 2021 and 2023[6,7,8]. Similarly, the global tally of COVID-19 pandemic cases as of June 9^th 2020, reached 7,039,918 confirmed cases with 404,396 deaths and 3,596,972 that recovered[6,8]. The setback to malaria control between 2020 to 2023, has been attributed to the negative impact of SARS-CoV-2, on malaria prevention, diagnosis and treatment [2,3,4] and may have detrimental effects on prevention and treatment outcomes of tuberculosis (TB), Human Immune Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and malaria, whose ending is part of United Nations 2030 Agenda and Sustainable Development Goals[15,20]. Uganda ranks third in the total number of malaria infections after the Democratic Republic of the Congo and Nigeria [9,10,11,22].

The association between COVID-19 and malaria epidemics can be devastating, especially in low and middle income countries (LMICs)[24]. Such countries are characterised by healthcare systems that are already fragile due to weak infrastructures, a scarcity of health workers, medicines, supplies stock outs, and financial resources[3]. In this perspective, to avoid indirect short and long–term effects of COVID-19 pandemic[25] on malaria control programs and on healthcare systems of countries where the two diseases can coexist, preparedness is critical[26]. For these reasons, in order to explore the current landscape and future outlook for a joint scenario of COVID-19 and malaria and the consequences thereof,[12,13]. In this review we describe yet another dimension of the integrated prevention and control strategies with the aim of providing comprehensive review of integrated approaches for both malaria and COVID-19 management in Uganda[5].

2. Methodology and Sources of Information

A narrative literature review was undertaken. Narrative reviews are useful studies that summarise and analyse existing research on a topic, providing an overview of the current understanding. We conducted an electronic literature search and included all the relevant scientific peer reviewed publications written in English language in 10 online data bases; Pub Med, Cochran, Medline, Google scholar, malarial journals, health journals, MDPI and biomed central which contained the desired terms in the title, abstract or key words[28]. From the 165 articles identified in the database and journal searches, 133 research articles with publication dates between 2004 and 2024, concerned with COVID-19 and malaria management, reported qualitative or quantitative findings were included, analysed and discussed for better understanding of the historical background, aetiology, epidemiology, transmission, clinical signs and symptoms, diagnosis, comprehensive integrated management, prevention and control of malaria and COVID-19, impact of measures, challenges and recommendations. Non- scientific commentary and news articles were excluded from the review paper. The search terms were prevention and control of Malaria and COVID-19[29].

All the findings and statements in this review regarding malaria and COVID-19 are based on published information as listed in the references.

3. Aetiology

a. Coronavirus Disease- 2019

The unprecedented severe acute respiratory coronavirus disease (COVID-19) pandemic is caused by a highly transmissible and pathogenic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)[29,30]. Variants of concern include but not limited to Alpha, Delta, Omicron, Zeta, Eta, Beta, Lota, Kappa, Mu, Lambda, and Gamma have impacted transmission rates and disease severity[31]. At the same time, these emerging novel variants have raised serious public health international concerns about vaccine efficacy and safety[16,32]. The nucleocapsid protein of SARS-CoV-2 packages the viral RNA to form a helical capsid and is essential for viability[33]. The SARS CoV-2 is 26 to 32kb, it encodes 16 non-structural proteins (nsp1-16) that are crucial for viral replication, 11 accessory proteins (ORF3a, ORF3b, ORF3c, ORF3d, ORF6, ORF7a, ORF7b, ORF8, ORF9b, ORF9c, ORF10) and 4 structural proteins; spike, membrane, N protein and envelope (S,M,N, and E)[34]. These proteins collectively help the virus evade the host ‘s immune system, enhancing its ability to infect and replicate[35]. Figure 1. The N protein coats the genome, while the S, M, and E proteins are embedded in the lipid envelope[34,36].

b. Malaria

The disease is caused by unicellular protozoan parasites belonging to the genus plasmodium[37]. These parasites infect not only humans but also other vertebrates, from reptiles and birds to mammals[37]. Plasmodium species naturally infect humans and cause malaria through the bites of female Anopheles mosquitoes [38]. There are over 400 different species of Anopheles mosquitoes and around 40 known as vector species can transmit the disease[1,39].The plasmodium parasites that infect people with malaria cannot survive outside of their hosts blood (humans and Anopheles mosquitoes)[39]. There are more than 150 blood parasites of the genus Plasmodium. However, only four species of malaria parasites cause significant disease in humans in Uganda[40]. The 2 most common species are Plasmodium falciparum and Plasmodium vivax pose greatest threat[40,41]. P. falciparum is the most prevalent, causes the majority of severe malaria cases and deaths, whilst P. vivax causes relapsing malaria, with a blood and a liver infection causing acute and ongoing symptoms. The less prevalent other 2 species are Plasmodium ovale, and Plasmodium malariae[42,43].

c. The Morphology and Life Cycle of the Plasmodium Parasites

The Plasmodium parasites are characterised by a variety of shapes ranging from round or oval forms in different life stages[44]. The plasmodium parasites range from 1 to 2 micrometers in diameter, with complex life cycle which involves two hosts: humans and Anopheles mosquitoes[45]. The cycle begins when an infected female Anopheles mosquito bites a human, injecting sporozoites (the infectious form of the parasite, elongated and motile) into the bloodstream[46]. The sporozoites travel to the liver, where they invade liver cells (hepatocytes)[47]. Inside the liver cells, they develop into schizonts and then rupture to release merozoites into the bloodstream, visible during certain stages of infection[45]. In some Plasmodium species notably (P. vivax and P. ovale), some parasites can form dormant stages called hypnozoites. These can remain inactive in the liver and reactivate later, causing relapses of malaria[45,48]. Invasion of Red Blood Cells (RBCs) occurs when merozoites released from the liver infect red blood cells. Inside the RBCs, the merozoites develop into trophozoites- the ring stage Figure 2, then mature into schizonts. Each schizont produces more merozoites[48]. The schizonts eventually rupture, releasing new merozoites into the bloodstream, which can then infect other red blood cells[45]. This stage is responsible for the symptoms of malaria (fever and chills). Some merozoites develop into gametocytes (the sexual stage of the parasite) within RBCs [49]. These gametocytes can be taken up by another mosquito during a blood meal. When a mosquito bites an infected person, it ingests the gametocytes along with the blood meal[37]. Inside the mosquito’s gut, gametocytes mature into male and female gametes, which then fuse to form a zygote[49]. The zygote develops into an ookinete, which penetrates the mosquito’s gut wall and forms an oocyst[50]. Within the oocyst, sporozoites develop and are eventually released into the mosquito’s haemolymph[49]. The sporozoites migrate to the mosquito’s salivary glands, ready to infect a new host when the mosquito feeds again[47,44]. This cycle continues as mosquitoes bite infected humans, perpetuating the transmission of malaria. Therefore, understanding this life cycle is crucial for developing strategies to prevent and treat malaria[44,50].

4. Epidemiology

The World Health Organisation (WHO) declared the outbreak of SARS-CoV-2 to be COVID-19 a pandemic on March 11, 2020[7,16]. The first cases were identified in Wuhan, China, in December 2019[16]. It spread to other areas of Asia, and then worldwide as of 17 August 2020, based on WHO reports, 21,689,832 confirmed cases and 770,273 deaths were reported globally[16]. COVID-19 epidemiology appears to vary across Africa, most countries in this region have reported relatively lower- case counts compared to the West. Nevertheless, the COVID-19 pandemic has added an additional burden to already overstretched healthcare system in sub-Sahara Africa (SSA)[16,51]. Quantifying now, the real numbers of COVID-19, SARS-CoV-2 cases is not easy since many different challenges are affecting surveillance systems over the world, from laboratory capacities to delay in case notification [5]. Although the mortality estimate is around 2%, different approaches to death cause monitoring and notification among different countries could affect this estimates [52,53].

In Uganda, COVID-19 has had a significant impact on the Country since the first case was reported in March 2020, involving a traveler from Dubai. By mid-2020, community transmission became evident, with clusters of death and cases per million people reported[35,54]. Uganda has experienced multiple waves of COVID-19, with varying peaks in cases and deaths relative to people with 410 cases and 0 death as of 1^st June 2020, 40,213 cases and 330 deaths as of 23 Feb 2021, 121587 cases and 3099 deaths as of 13 September 2021, 163805 cases and 3596 deaths as of 31 March 2022, 169,281 cases and 3630 deaths as of 17 October 2022, 170,671 cases and 3632 deaths, 6 May 2023, 171888 cases and 3632 deaths as of 21 November 2023, 172,159 cases and 3632 deaths as of 22 September 2024[55,56,57].The mortality rate increased rapidly from June, 2020 to October, 2022 with irreversible economic losses[58]. The number of confirmed cases fluctuated due to factors such as variants of concern associated with increased transmissibility or different symptoms profiles, public health interventions, age and comorbidities as older adults with underlying health conditions like diabetes, hypertension are more likely to experience severe symptoms[62,63,64,65].

Meanwhile, malaria is still considered a huge killer, representing one of the biggest health challenges in the world, especially context of poverty[61]. According to the latest World Malaria Report, 2023[39,62], there were an estimated 233 million cases and 576,000 deaths of malaria globally in 2019 compared to the global tally of 249 million case and 608,000 deaths in 2022 well above estimated number of cases before the COVID-19 pandemic[18,62]. The Africa region holds the sad record of having more than 90% of global malaria cases, followed by Southeast Asia and then the Eastern Mediterranean Region[39,63]. Six countries accounted for more than half of all malaria cases worldwide: Nigeria (25%), the Democratic Republic of Congo (DRC) (12%), Uganda (5%), Ivory coast and other two (4%) each [9,64]. Moreover, malaria remains a significant public health challenge in Uganda, with the country bearing a high brunt of the disease in 2022. The population at risk 47,249,584 and 4817 reported deaths, 17,556 estimated deaths, 20,012,873 presumed & confirmed cases, 12,651,126 estimated cases, with under 5 mortality rate per 1000 live births (2020) * of 43.316. [18,67,68,69]. Malaria is highly endemic 96% across most parts of Uganda, with varying transmission rates. Northern and western regions often experience higher transmission compared to some urban areas[67,68]. Regions of West Nile and Acholi have very high transmission intensity with malaria incidence above 450 cases/ 1000 population. Lango, Karamoja, Teso, Bukedi, and Busoga regions have medium transmission intensity (malaria incidence between 251- 450 cases/1000 population) [69,75]. The prevalence therefore, varies by region. Different studies indicate that, children under five years old, pregnant women, travelers and people with weakened immune systems are at higher risk of severe malaria and death[7,71].

5. Transmission and Spread

The typical incubation period is about 4-5 days, but it can range from 2 to 14 days[31,72]. Primarily contagious and highly infectious diseases which spreads through respiratory droplets when an infected person coughs, sneezes, talks, with person unlike malaria[7,72]. Similar studies elsewhere, indicate that person-to- person contact by asymptomatic carriers also play an important role[76]. Another study by Paul Weiss, 2020 states it can also spread via aerosols, especially in enclosed, poorly ventilated spaces, and through contact with contaminated surfaces[73]. Contact transmission of COVID-19 occurs when contaminated hands touch the mucosa of the eyes, nose or mouth[26,75]. It can also be transmitted between surfaces via contaminated hands[73,76].

Malaria is a serious and sometimes fatal disease caused by parasites of the genus Plasmodium, which are transmitted to humans through the bites of infected female Anopheles mosquitoes, which are the vectors for malaria[37,71]. Malaria transmission in Uganda follows similar patterns to those in other SSA countries but is influenced by specific local factors, such as: climate, water sources, poor housing conditions, seasonal variations (rainy seasons) [78,79,80]. In another study done by Meibalan E. et al, 2018 suggest that the risk of transmission and infection is higher in some areas than others depending on multiple factors like rainy season, including the type of local mosquitoes[24]. Malaria as a life threatening disease found in Uganda, it is both preventable and curable[79,80]. In many regions, malaria transmission is seasonal and corresponds with the rainy season, which increases mosquito breeding sites[79]. Understanding the transmission and spread of malaria is crucial for effective prevention and control[3,81]. By addressing the factors that contribute to mosquito breeding and ensuring access to preventive and therapeutic measures, the impact of malaria can be significantly reduced[82].

6. Clinical Signs and Symptoms

Malaria presents with a range of clinical signs and symptoms that vary depending on the species of Plasmodium, the severity of the infection, and the individual’s immune status[39]. The symptoms and signs of malaria usually begins within 10-15 days after the bite from an infected female Anopheles mosquito[50]. In the study about COVID-19 and malaria: A symptom screening challenges for malaria endemic countries, malaria shares some of the highly recognizable symptoms with COVID-19 such as; fever, headaches of acute onset, fatigue, difficulty breathing and malaise. Thus, a malaria case may be misclassified as COVID-19 if symptoms alone are used to define as case during clinical diagnosis and vice versa[61,70] The signs and symptoms begins after incubation period within 10-15 days; multi-organ failure is common in severe cases among adults while respiratory distress is also expected in children with malaria, mimicking what is usually reported in patients with COVID-19[70,83]. In malaria endemic areas, people who have developed partial immunity may become infected but show no symptoms[39,84]. If P. falciparum malaria is not treated within 24 hours, the infection can progress to severe illness and death[44]. Severe malaria can cause complications; renal failure, circulatory collapse, hypoglycemia, haemoglobinuria, and pulmonary oedema in adults, while children frequently suffer from severe anaemia, acute respiratory distress syndrome (ARDS), gastrointestinal distress and cerebral malaria with repeated convulsions[10,63,85]. Human malaria caused by other p. species can cause significant illness and occasionally life threatening disease[48,86].

COVID-19, can present with a wide range of clinical signs and symptoms[5,87,88]. The severity can vary from mild to severe manifestations and can include[8,16]: fever with chills, elevated body temperature, often above 100.4°F (38°C), persistent dry cough, difficulty breathing, fatigue, muscle or body aches, headache, sore throat, loss of taste or smell, nasal congestion or discharge, nausea or vomiting and frequent diarrhea[8,16,36], while severe COVID-19 manifestation can cause complications like acute respiratory distress syndrome and pulmonary embolism[36,89].

7. Diagnosis of Malaria and COVID-19

World Health Organisation (WHO) recommends prompt diagnosis for anyone with suspected malaria[18]. Malaria can be commonly diagnosed using blood smear for microscopy tests to determine the presence of the parasites causing the disease[84]. Alternatively, Malaria Rapid Diagnostic Test (mRDT) designed to detect specific malaria antigens in a patient's blood, providing results in a short period, typically within 15-30 minutes[90]. In the study about health workers adherence to malaria T3 strategies by RK Mumali et al, 2023, malaria diagnosis involves two common tests in Uganda: Microscopic examination of blood smears (BS-MPs) , which is the gold standard and mRDT to diagnose malaria quickly and accurately, easily accessible and help avoid unnecessary treatment for patients who do not have malaria, thus preventing the misuse of antimalarial drugs and reducing the risk of drug resistance[8]. mRDTs target specific malaria antigens, such as P. falciparum histidine-rich protein 2 (HRP-2) or Plasmodium lactate dehydrogenase (pLDH)[65,92]. These antigens are produced by the malaria parasites and are present in the blood of infected individuals[93]. The diagnostic testing enables health care providers to distinguish malaria from other causes of febrile illness, facilitating appropriate and prompt treatment[23,84]. Early diagnosis and treatment are crucial to managing malaria effectively and preventing complications[90].

COVID-19 pandemic diagnosis involves a combination of clinical evaluation, laboratory testing using nasopharyngeal or oropharyngeal swab, and sometimes imaging[29]. It's crucial to follow current guidelines and diagnostic protocols[16]. Initial assessment, Includes evaluating symptoms and exposure history[16]. If COVID-19 is suspected, appropriate testing using Polymerase Chain Reaction (PCR) test is performed as a gold standard for diagnosing COVID-19, which detects the presence of viral RNA detecting the N gene and E gene in a sample[94]. Based on test results, the diagnosis is confirmed[73]. In some cases, especially with rapid tests, a follow-up PCR may be recommended for confirmation[75]. Positive cases are managed based on the severity of symptoms, ranging from isolation and home care for mild cases to hospitalization and advanced care for severe cases[29,36].

Clinical evaluation based on the common clinical signs and symptoms manifested during COVID-19 infection as described in section 6. (clinical sign and symptoms of COVID-19)[95]. However, symptoms can vary and may include asymptomatic cases[95]. Moreover, to detect viral proteins (antigens), rapid antigen tests using rapid diagnostic tests (RDT) can provide results within 15-30 minutes though less sensitive than PCR tests[96]. Elsewhere, other scholars have stipulated that, imaging- CT Scan or Chest X-Ray imaging can show patterns of lung inflammation or damage associated with COVID-19[97]. Using COVID chest X-ray pictures, researchers in this work developed a strategy that combined pictures regrouping with Res Net-SVM[75]. An automated technique to detect the COVID-19 pandemic depending upon chest X-rays and CT scan pictures of patients was examined in research[97,98]. However, it is not used for initial diagnosis but may be employed to assess the severity of lung involvement if the diagnosis is already confirmed[53].

8. Malaria and COVID-19 Comprehensive Integrated Management Approaches

Management of malaria during the COVID-19 pandemic in Uganda required a comprehensive approach that balances the need for both malaria and COVID-19 prevention, control and treatment[5,94]. Such management strategies that could be implemented include:

Improved healthcare infrastructure strengthening to handle the dual burden of malaria and COVID-19 cases[99,100]. This includes increasing the number of primary healthcare facilities and systems right from health Centre II’s, III’s, IV’s, district hospitals, Regional Referrals and National Referral Hospitals[35], ensuring availability of essential medicines and medical supplies, equipment, and trained, competent human resource as well as training healthcare workers on managing both diseases[101]. Strengthening healthcare systems involves upgrading a country’s healthcare systems through increased funding for health infrastructure, health policy improvement, and universal health coverage (UHC)[101]. Failure to achieve this has contributed to high mortality rates among continent’s vulnerable groups[73,101].

Integrated services of malaria with COVID-19 testing and treatment centres were feasible during COVID-19 pandemic outbreak of 2019 to date in Uganda[99]. In the study by Rogerson et al, 2020 about identifying and combating the impact of COVID-19 on malaria, this integration helped streamline healthcare service delivery and ensuring that individuals presenting with fever or other symptoms of either COVID-19 or malaria like fever, were screened for both diseases simultaneously and managed accordingly as per stipulated by Ministry of Health (MOH) management guidelines and other international standards[102,103].

Mobile Health (mHealth) Solutions, the most common application of mhealth is the use of mobile devices to educate consumers of health services about preventive healthcare services[104]. To counter the pandemic, Uganda must design sustainable plans give inherent disparities in wealth and health care systems[104]. In Uganda, mhealth solution by malaria consortium is used to improve community health worker motivation and performance[105]. Utilization of mobile technology to provide remote consultations, disseminate health information, and track COVID-19 and malaria cases[106]. Mobile apps could be developed to facilitate self-reporting of malaria symptoms, allowing healthcare providers to monitor and respond to outbreaks in real-time. However, mhealth is also used for disease surveillance, treatment support, epidemic outbreak tracking and chronic disease management[106].

Launching community-wide education campaigns to raise awareness about malaria and COVID-19 prevention and control measures[3,107] such as the use of insecticide-treated bed nets, proper sanitation, proper hygiene including hand washing, use of face masks and seeking early treatment for malaria and COVID-19 symptoms were order of the day[5,7]. These were made through national television broadcasts, state of national address by his excellence the president of republic of Uganda H.E Gen.Yoweri Kaguta Museveni[108].

Expanded surveillance and screening for cases according to established guidelines to control the spread among the population[75]. The WHO has emphasized that the response to COVID-19 pandemic must utilize strengthened existing infrastructure for addressing malaria and other infectious diseases globally[106]. Leveraging on these to maintain malaria control activities in Uganda could boost and help to sustain the gains in malaria control in accordance with 2016 to 2030 Global technical strategy for malaria (GTS) milestone. In addition, it will help to keep the high burden to high impact (HBHI) and other initiatives on track[106]. Furthermore, scaling up COVID-19 and malaria testing capacity by deploying rapid diagnostic tests (RDTs) to community health centers and mobile clinics under universal coverage for all is very significant in screening cases there by control or preventing the transmission[4]. This encourage individuals experiencing fever or other malaria and or COVID-19 signs and symptoms to seek prompt testing and treatment in public health care facilities at a free cost[76]. Increased access to rapid diagnostic tests for both diseases, plays a key role in surveillance in remote areas[96,109]. There is however, need for strengthened or established robust surveillance system to detect and track both malaria and COVID-19 prevalence and trends[106]. Ongoing surveillance is also essential for tracking the spread of the virus, monitoring new variants, and assessing the effectiveness of interventions [96].

Collaborations with local health authorities such as Village Health Teams (VHTS) that support in sensitization and mobilization and research institutions like Uganda Virus Research Institute (UVRI) to conduct epidemiological studies and evaluate the impact of interventional strategies[110].

An uninterrupted access to treatment like antimalarial drugs, COVID-19 vaccines and by maintaining adequate stock levels at healthcare facilities and implementing distribution mechanisms through National Medical Stores (NMS) to reach remote areas has been the responsibility of the Ugandan Government under the MOH as a line ministry[107,108]. Implementing Partners such as malaria consortium, TASO, Baylor, USAID, Uganda Cares, etc considered and implemented alternative delivery methods such as home delivery or community distribution points and testing and vaccination outreaches in partnership with the MOH in order to minimize the risk of COVID-19, malaria, HIV/AIDS and Tuberculosis (TB) transmission[24].

Health Worker training, to enhance competency and professionalism which involves capacity building process by providing in-service training and mentorships to healthcare workers on the identification, diagnosis, and treatment of both malaria and COVID-19[111]. Much emphasize exerted on infection prevention and control measures to minimize the risk of occupational healthcare-associated transmission and ensure safety as well[112].

Community engagement and participation Involving communities in prevention and control efforts through community health workers, local leaders, local organizations, and traditional healers in malaria prevention and COVID-19 control efforts is crucial[90]. Fostering partnerships with community-based organizations to promote health-seeking behaviors especially among men and encourage adherence to preventive and control measures[113]. There is also need to encourage community participation in activities such as vector control, health education, and early case detection[3,108].

Research and Innovation through government support towards research for development initiatives aimed at developing new diagnostic tools and strategies for malaria control in the context of the COVID-19 pandemic,[112]. Exploring innovative approaches like use of treated baby wraps (lesus), drones for mosquito control, development of new vaccines, drugs, and diagnostic technologies, as well as innovative approaches for vector control and community engagement. Continuous research focused on understanding the virus, developing treatments, and improving vaccines is a cornerstone in SARS-CoV 2 prevention and control[96].Cross-Sector collaboration in the management of infectious diseases, by fostering collaboration between health sectors, government agencies, non-governmental organizations, and other stakeholders to coordinate efforts and share resources for malaria and COVID-19 control[16].

Strengthened international cooperation and collaboration to address the dual burden of malaria and COVID-19, particularly in regions where both diseases are endemic[1,3]. This includes sharing best practices, exchanging data and resources, and providing support to countries with limited healthcare infrastructure[114].

9. Prevention and Control of Coronavirus Disease- 2019

Vaccination against COVID-19 pandemic is key as it protects individuals from catching disease and also promotes herd immunity[4,115]. The development of COVID-19 vaccines has been progressing at an unprecedented rate[116]. Scientist across the world are racing to produce efficacious and safe vaccines, many of which are in use or have under gone clinical trials [7,117]. Owing to the current challenges and myths associated with use of available COVID-19 vaccines against the disease for now, non –pharmacological measures are being applied to cattail the spread of the COVID-19 SARS CoV2 virus[2]. As of August 2024, Uganda has been managing its COVID-19 situation with a mix of public health measures and vaccination efforts[15,29]. The Ugandan government imposed control and preventive measures which include[76]; lockdowns, curfews, restrictions on gathering, physical or social distancing (1.5m), hand hygyiene by washing hands regularly with soap or disinfecting with sanitizers containing at least 70% alcohol (ethanol), using face masks, refraining from touching eyes, nose, and mouth with unclean hands, covering coughs and sneezes with tissues, avoiding contact with infected people[89,118].

Public health guidelines and measures such as physical distancing is one of the measures being applied in public to curb the transmission of the virus[14]. This is the act of keeping space between oneself and other people in the general public. It involves staying at least 6 feet away from other people, not gathering in groups and avoiding crowded places or mass gathering[119].

Testing and contact tracing have been critical in identifying and isolating cases to control the spread [106].

Hand hygiene is the most effective single practice that can be used to decrease the spread of infections through multimodal measures[103,120]. Therefore, hand hygiene is paramount in preventing the spread of the COVID-19, other viruses and bacteria, by washing hands regularly with soap or disinfecting with sanitizers containing at least 70% alcohol (Ethanol)[120,121]. Furthermore, healthcare workers are encouraged to observe the five moments of hand washing hygiene[120].

10. Prevention and Control of Malaria

Uganda has implemented several strategies to reduce the burden of malaria, caused by the parasite Plasmodium falciparum, including distribution of insecticide-treated nets, indoor residual spraying, and intermittent preventive treatment in pregnancy.

Vaccination is the effective way of prevention of diseases. Currently there are two malaria vaccines recommended for use in children living in moderate and high malaria transmission areas[62,18,122] CDC, 2019-2020 (https://www.cdc.gov/malaria/php/public-health-strategy/malaria-vaccines.html website). However, the key vector control measures applied include the use of insecticide-treated mosquito nets (ITNs) and Indoor residual spraying (IRS) with insecticides. Indoor residual spraying (IRS) IRS involves applying insecticides to indoor surfaces to kill mosquitoes. Uganda implements IRS in phased approaches in both endemic and epidemic-prone areas using WHO-approved insecticides[123]. Insecticide-treated nets (ITNs), particularly long-lasting insecticidal nets (LLINs), are a core component of Uganda's malaria control efforts and are distributed through mass campaigns and routine channels like antenatal care and immunization clinics. LLINs containing pyrethroid and piperonyl butoxide (PBO) have been shown to reduce parasite prevalence more effectively than conventional LLINs. [123,124,125,126] In a cluster- randomized trial by Sarah G Staedke et al 2022, LLINs with piperonyl butoxide (PBO) reduced parasite prevalence more effectively from 28.8% to 17.1% at 25 months[124], . Larviciding and environmental management, using chemical and biological larvicides, is appropriate, selective, cost-effective, and sustainable as environmental management measures are also applied, in order to reduce mosquito breeding sites. This is a key measures to achieve malaria elimination in Uganda. Still, compliance with these measures remain a challenge[3,127]. Chemoprevention which involves prophylactic treatment for travelers and seasonal malaria chemoprevention (SMC) for children under five in high-transmission areas, are key strategies to reduce the incidence of malaria [128]. People living in endemic areas progressively acquire a semi-immune status after repeated infections, reducing acute infection symptoms and disease severity. Nevertheless, after several years spent in one endemic country, immunity may be partially lost, as occurred in migrants from endemic countries to Europe or North America[128]. Early diagnosis and effective treatment with antimalarial drugs. The Uganda Ministry of Health recommends prompt treatment with artemisinin-based combination therapies (ACTs) for confirmed malaria cases[129]. Uganda adopted Artemisinin-based combination therapies (ACTs) as the first-line treatment for P. falciparum malaria in 2004[65,128]. Improved access to case management has contributed to a significant reduction in malaria-related deaths, with the proportion of malaria deaths in health facilities decreasing from 7% to 4.8%.

Intermittent preventive therapy (IPT) in school-aged children (IPTsc) was recommended by WHO in 2022 as a malaria reduction and control strategy in areas with moderate to high perennial or seasonal transmission and the IPTsc with dihydroartemisisnin-piperaquine has been shown to be highly effective in Uganda[125].

11. Impact of Measures to Reduce P. falciparum Malaria Incidence and Mortality

The implementation of these interventions has led to a significant decrease in malaria burden over the last decade; however, these gains are fragile and can be reversed if key interventions cease.

The Uganda Malaria Reduction Strategic Plan 2014–2020 incorporated findings from a mid-term review to accelerate the scale-up of evidence-led malaria reduction interventions. The subsequent plan developed in 2022 aims to reduce malaria infection and morbidity by 50% and mortality by 75% by 2025[130]. Uganda launched its fourth Malaria Indicator Survey in 2024-2025 to provide crucial data on malaria prevalence, prevention efforts, and the overall impact of interventions. The survey is conducted every three years[131]. Studies are conducted to monitor trends in malaria morbidity and mortality and track the impact of control interventions. These studies have informed Uganda’s malaria treatment policies, guided the selection of LLINs, and revealed pyrethroid resistance, leading to changes in insecticides used for IRS[123].

Integrated vector management (IVM) strategies involve using a combination of interventions based on local vector biology and disease transmission patterns[130]. These strategies also include collaboration within the health sector and with other public and private sectors, advocacy for public health regulations, promotion of rational insecticide use, and community engagement[108]. The Supporting Uganda's Malaria Reduction and Elimination Strategy (SUMRES) project aims to reduce malaria morbidity and mortality in specific districts in northern Uganda. Despite this progress, malaria remains a major public health problem in Uganda[125]. In 2023, there were an estimated 12.6 million malaria cases and over 15,945 deaths in the country. Uganda is the 3rd highest contributor of malaria cases and 7th highest contributor of malaria deaths globally[18,132]. Malaria accounts for 30-50% of outpatient clinic visits, 15-20% of admissions, and up to 20% of in-patient deaths[9]. The treatment of malaria is very expensive, preventing it is more cheaper[133]. The most direct economic benefit to reduce malaria prevalance is the associated reduction in household health expenditures. There is strong evidence that utilization of malaria control strategies at the community level are highly protective against malaria infection[134]. Although a different study indicated that increased use of LLINs contributed the most case reduction[135]. However, the lack of effectiveness could be due to the low utilization of interventions or the low levels of malaria transmision in the area[134,136].

12. Challenges

Besides being a leading cause of morbidity and mortality, malaria is also a cause and consequence of rampant poverty in Uganda, where current control efforts are mainly frustrated by antimalarial drugs and insecticide resistance, particularly artemisinin, poses a significant challenge to malaria control efforts. Widespread mosquito resistance to insecticides used like Pyrethroid threatens the effectiveness of vector control interventions too. The degree of control that can be attained with LLINS and IRS is limited by a combination of factors including barriers to achieving and sustaining universal LLINs coverage in Uganda, coupled with the resource intensive nature of IRS programs, and the emergency of insecticide resistance[123]. In addition, these household-based interventions can drive selection pressure, where mosquitoes feeding behaviors a voids the interventions and feeds early evening when residents are outside the home. Studies in Uganda and elsewhere have demonstrated short lifespan of less than 3 years of LLINs highlighting the important challenge of net attrition[124].

Economic and health system constraints including inadequate healthcare infrastructure and resources in many endemic areas can hinder effective malaria and COVID-19 prevention, control and treatment.

Healthcare workforce limitations; Malaria control faces significant healthcare workforce limitations, especially in regions like Northern Uganda. These include shortages of trained competent staff, systemic inefficiencies, and high turnover due to poor conditions. Fragmented services, inadequate training, and poor adherence to guidelines further undermine efforts. Gender disparities also impact guideline adherence. Uganda's low healthcare workforce to patient ratio exacerbates these challenges, hindering effective malaria prevention and treatment.

Noncompliance with prevention measures is a significant challenge with adherence to existing malaria prevention strategies. For instance, despite the distribution of ITNs, improper usage or repurposing of these nets for non-health-related activities like fishing and protecting nursery beds is common. Furthermore, logistical hurdles, not limited to stock outs but also access to essential commodities for COVID -19 and malaria remain a challenge in Uganda. This includes vaccines, diagnostic tools, and treatments necessary for effective disease management.

Cultural factors significantly influence malaria prevention and control by shaping how communities perceive and respond to interventions. Traditional beliefs, such as attributing malaria to supernatural causes, can lead to reliance on traditional healers instead of medical treatments, while cultural resistance to change may hinder the adoption of insecticide-treated bed nets. Gender roles, social norms, economic constraints, and reluctance to alter daily routines further complicate control efforts. Effective health communication tailored to local customs and utilizing trusted community leaders is crucial to overcome misinformation and promote consistent use of preventive measures, ultimately improving malaria control outcomes.

Despite these challenges, there have been achievements. Recent progress includes the availability of universal access of various COVID -19 vaccines provided by the government like; Pfizer-BioTech, Moderna, AstraZeneca/Oxford, Sinovac, Covovax, COVAXIN, Sinopharm,and J&J Vaccines(WHO, 2023). The launch of the first malaria vaccine, RTS,S/AS01, and the endorsement by WHO of a second vaccine, R21/Matrix-M. Additionally, the deployment of new dual-active ingredient insecticide-treated nets and expanded malaria prevention for high -risk children have been crucial advancements offering new avenues for combating the disease. In Uganda high malaria districts like Tororo and Serere in Eastern Uganda have benefited from other counter measures like indoor residual spray (IRS).

Conclusion and Recommendation

During COVID-19 pandemic, the malaria cases rose, by implementing this comprehensive integrated, multifaceted, management strategies, that addresses the public threat posed by malaria and the COVID-19 pandemic and malaria epidemic, we can mitigate the impact, of both diseases, effectively manage both malaria and COVID-19, reduce the burden of disease, and protect the health and well-being of communities worldwide. This review paper underscores that the path towards COVID-19 and malaria elimination will require a comprehensive and integrated approach, that balances the need for both malaria and COVID-19 control, prevention and treatment. This means significantly ramping up both financing and political commitment to support the fight against the disease. It will also mean using data strategically and harnessing innovation to develop new COVID-19 and Malaria control tools that can complement existing interventions and address growing challenges, enhance intervention strategies. To make headway, this review recommends that innovation focus on actively funding, advanced research towards antimalarial drugs and insecticide resistance with the aim of averting resistance. To meet malaria elimination targets, special focus will have to be on regions that contribute the highest to the malaria burden. while implementing universal LLINs and IRS coverage in Uganda. To maximize the benefits of LLINs, strategies to ensure high LLIN coverage, including more frequent mass campaigns, involving local leaders, distribution of adequate numbers of LLINs during campaigns, and strengthened routine distribution channels, should be deployed and supported by intensified social and behaviour change communication messaging. This can make communities better adopt and sustain malaria and COVID-19 prevention efforts. In addition, increasing access to these interventions and maintaining their effectiveness in the face of insecticide and drug resistance, should form a cornerstone of post-2025 prevention and control strategies.