From Endemic to Epidemic: A Qualitative District-Level Assessment of an Increase in Malaria Cases in the Elgon Region of Uganda.

With an estimated 5% of global cases, Uganda carries the third-largest burden of malaria. Despite years of focus on malaria by Uganda's Ministry of Health, the malaria incidence rate increased from 206 to 271 cases per 1,000 population between 2012 and 2022. We aimed to identify gaps in malaria prevention, detection, and response in the high-burden Elgon region of Uganda. We collected data from the Ugandan District Health Information Software 2 database to identify districts with the highest incidence of malaria within the Elgon region. We used a structured assessment tool to conduct key informant interviews of district health officers, malaria focal persons, and vector control officers within each district. Qualitative data were analyzed using immersion-crystallization methodology, with multiple independent reviewers extracting major and minor themes within the framework of prevention, detection, and response. Within the category of prevention, the main theme was a lapse in vector control strategies. The major themes in the detection and response categories were lack of timely logistical support and limited chemotherapeutics, respectively. Of the 10 districts assessed, 7 (70%) had inadequate access to insecticide-treated nets, 3 (30%) had no active indoor residual spraying program, and 8 (80%) had limited or no availability of rapid diagnostic tests at the time of the assessment. The mean (±SD) time since the last resupply for antimalarial medications from the central governmental supply was 117 (±9) days. The extracted themes highlight areas for intervention within high-burden districts in eastern Uganda.