Sub-national Variation and Heterogeneity of Malaria transmission and Antimalarial Drug Utilization in Fifteen Endemic Sub-Regions of Uganda

Sub-national Variation and Heterogeneity of Malaria transmission and Antimalarial Drug Utilization in Fifteen Endemic Sub-Regions of Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sub-national Variation and Heterogeneity of Malaria transmission and Antimalarial Drug Utilization in Fifteen Endemic Sub-Regions of Uganda Bosco B. Agaba, Edgar Agaba, Thomas Katairo, Isaac Sewanyana, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8948718/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Uganda is the third largest contributor to the global malaria burden. Despite decades of investment in control interventions, the entire population remains at risk of exposure to infective mosquito bites, malaria morbidity and mortality. The WHO recommends epidemiological stratification and sub-national tailoring of malaria interventions based on local transmission given the heterogeneity of malaria transmission, however current malaria transmission data at sub-national level is often lacking. Methods: From October 2024 to April 2025 using a cross-sectional design, blood samples were collected from children <5 years for Rapid Diagnostic Tests (RDTs) and thick blood smears to assess presence of malaria parasites. Interviews were conducted with caretakers in household using an electronic Questionnaire to collect respondents’ demographic variables as well as the antimalarial drug use pattern. Data were analysed with STATA and the Geographical Information System (ArcGIS) software and reported as proportions and geospatial maps at sub-national levels. Results: Throughout the study period, interviews were completed in 9,238 caretakers while blood samples were collected from 6,802 children. Based on blood smear microscopy 13% of children were positive for malaria parasites. At sub-national level, there was substantial variation in parasite prevalence with the highest seen in Lango (32%), Karamoja (26%), Acholi (23%), Teso (23%) and Busoga (21%) while Kampala (<1%) and Kigezi (1%) had the lowest. Artemisinin based combination therapy (ACT) was the major drug used for malaria treatment (87%), however the use of artemisinin monotherapies and non-artemisinin compounds for treatment of malaria was reported among respondents. Conclusion: The study provides current estimates of parasite prevalence at national scale and demonstrates wide variation and heterogeneity of malaria transmission across the subregions in Uganda. The substantial regional variation and high heterogeneity of malaria transmission observed across the subregions suggests the need for malaria epidemiological stratification and sub-national tailoring of interventions by the national malaria program in Uganda. Key words: Malaria parasites, Malaria transmission, sub-national parasite estimates, stratification and sub-national tailoring Malaria parasites Malaria transmission sub-national parasite estimates stratification and sub-national tailoring Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 May, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviewers invited by journal 04 Mar, 2026 Editor assigned by journal 24 Feb, 2026 Submission checks completed at journal 24 Feb, 2026 First submitted to journal 23 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8948718","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":601605678,"identity":"5a1baa52-3f19-4711-8dd4-e0884c7630d7","order_by":0,"name":"Bosco B. 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Collaboration","correspondingAuthor":false,"prefix":"","firstName":"Sam","middleName":"","lastName":"Nsobya","suffix":""}],"badges":[],"createdAt":"2026-02-23 15:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8948718/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8948718/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104205793,"identity":"55c15021-e2d7-4a68-8443-28c2a0cd9e9d","added_by":"auto","created_at":"2026-03-09 06:51:14","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":520917,"visible":true,"origin":"","legend":"","description":"","filename":"SubnationalestimatesofMalariainUgandaMAN1Finalpdf.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8948718/v1_covered_10efa793-fe48-4c80-8a3e-6ac3881714c6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sub-national Variation and Heterogeneity of Malaria transmission and Antimalarial Drug Utilization in Fifteen Endemic Sub-Regions of Uganda ","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malaria parasites, Malaria transmission, sub-national parasite estimates, stratification and sub-national tailoring ","lastPublishedDoi":"10.21203/rs.3.rs-8948718/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8948718/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Uganda is the third largest contributor to the global malaria burden. Despite decades of investment in control interventions, the entire population remains at risk of exposure to infective mosquito bites, malaria morbidity and mortality. The WHO recommends epidemiological stratification and sub-national tailoring of malaria interventions based on local transmission given the heterogeneity of malaria transmission, however current malaria transmission data at sub-national level is often lacking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e From October 2024 to April 2025 using a cross-sectional design, blood samples were collected from children \u0026lt;5 years for Rapid Diagnostic Tests (RDTs) and thick blood smears to assess presence of malaria parasites.\u0026nbsp; Interviews were conducted with caretakers in household using an electronic Questionnaire to collect respondents’ demographic variables as well as the antimalarial drug use pattern. Data were analysed with STATA and the Geographical Information System (ArcGIS) software and reported as proportions and geospatial maps at sub-national levels.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Throughout the study period, interviews were completed in 9,238 caretakers while blood samples were collected from 6,802 children. \u0026nbsp;Based on blood smear microscopy 13% of children were positive for malaria parasites. At sub-national level, there was substantial variation in parasite prevalence with the highest seen in Lango (32%), Karamoja (26%), Acholi (23%), Teso (23%) and Busoga (21%) while Kampala (\u0026lt;1%) and Kigezi (1%) had the lowest. Artemisinin based combination therapy (ACT) was the major drug used for malaria treatment (87%), however the use of artemisinin monotherapies and non-artemisinin compounds for treatment of malaria was reported among respondents. \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The study provides current estimates of parasite prevalence at national scale and demonstrates wide variation and heterogeneity of malaria transmission across the subregions in Uganda. The substantial regional variation and high heterogeneity of malaria transmission observed across the subregions suggests the need for malaria epidemiological stratification and sub-national tailoring of interventions by the national malaria program in Uganda. Key words: Malaria parasites, Malaria transmission, sub-national parasite estimates, stratification and sub-national tailoring\u003c/p\u003e","manuscriptTitle":"Sub-national Variation and Heterogeneity of Malaria transmission and Antimalarial Drug Utilization in Fifteen Endemic Sub-Regions of Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 06:50:57","doi":"10.21203/rs.3.rs-8948718/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"104844918709758567351460438218559715994","date":"2026-05-13T16:33:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289345949848405838128615574945487161419","date":"2026-03-31T17:38:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-04T16:05:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-24T05:33:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T05:26:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Global and Public Health","date":"2026-02-23T15:22:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-global-and-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [BMC Global and Public Health](https://bmcglobalpublichealth.biomedcentral.com/)","snPcode":"44263","submissionUrl":"https://submission.springernature.com/new-submission/44263/3","title":"BMC Global and Public Health","twitterHandle":"@BMC_GPH","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dd33a908-fec0-4f2f-8d04-82b913236f0f","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"104844918709758567351460438218559715994","date":"2026-05-13T16:33:50+00:00","index":57,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T06:50:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 06:50:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8948718","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8948718","identity":"rs-8948718","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}