Risk factors for death among children with severe malaria, Namutumba District, Eastern Uganda, September 2021 - February 2022

Abstract

Abstract Background: In February 2022, a high number of deaths among children was reported to the Ministry of Health from Namutumba District. The cause was later confirmed as severe malaria. We investigated the scope of severe malaria deaths, identified associated factors, and recommended evidence-based control measures to inform malaria-prevention programming in Namutumba District. Methods: We conducted an unmatched case-control study in March 2022 in the most affected subcounty (Ivukula Subcounty). We defined a case as death with a history of fever and any of the following: convulsions, difficulty breathing, yellow eyes, tea-colored urine, anemia, loss of consciousness, or reduced urine output in a child ≤12 years from September 2021 to February 2022 in Ivukula Subcounty, Namutumba District. Controls were survivors with the same signs and symptoms, recruited in a 2:1 ratio with cases. We actively searched for cases and controls door-to-door with the help of community health workers. We interviewed caretakers for cases and controls to obtain socio-demographic and clinical data, including health-seeking behavior and health systems risk factors. Drugs and bloodstock status information was obtained from health workers using an interview guide. We identified factors associated with death using multivariate logistic regression and thematic analysis for qualitative data. Results: Among 46 cases, 29 (63%) were <5 years, and 23 (50%) were female. Death among children with severe malaria was significantly associated with treatment non-completion (aOR=9.7, 95%CI: 1.8–53) and failure to receive blood transfusion for anemic patients (aOR=7.1, (95%CI: 1.4–36). Healthcare workers reported that failure to reach intended referral sites due to transport costs, stockouts of antimalarials and blood products at health facilities, and absence of integrated community case management of childhood illnesses (iCCM) were likely contributors to deaths among children with severe malaria. Conclusion: Incomplete or insufficient treatment due to lack of patient resources and drug stockouts contributed to malaria mortality among children ≤12 years in Ivukula Subcounty in Uganda. We recommend accurate quantification of antimalarials for health facilities, offering transport support to severe patients referred to higher-level facilities, and increasing access to blood products. Activation of iCCM could facilitate public health efforts against severe malaria in the district.