Can Nigeria achieve Malaria elimination?

World Malaria Day is celebrated across the globe on April 25 every year. It is a day to draw public attention to one of the greatest public health challenges, especially of low- and middle-income countries [e.g. Nigeria]. After this year’s celebration of the Day, Premium Times looks at some of the common myths surrounding the prospects of malaria elimination in Nigeria.

The theme for this year’s World Malaria Day was ‘Zero Malaria Starts With Me’. The World Health Organisation (WHO) said the campaign “aims to keep malaria high on the political agenda, mobilise additional resources, and empower communities to take ownership of malaria prevention and care.”

Preventable killer disease

Malaria is a life-threatening infectious disease caused by the Plasmodium parasites in the bite of infected female Anopheles mosquitoes, which acts as a vector for malaria. Although it is highly preventable and curable, it remains a top killer disease. Malaria affected 219 million worldwide in 2017, 435,000 of whom died as a result of the disease. Over the past years, global efforts have been made to curb the incidence of malaria.

There is ‘a malaria myth’ especially in Nigeria; that the disease cannot be eliminated and thus has to be managed. This perception is not surprising, as malaria is highly endemic in the country. According to WHO’s 2018 World Malaria Report, Nigeria now has the highest burden of the disease.

Nigeria’s High Malaria Burden

Malaria accounts for over 60 per cent of the total reported illness in Nigeria. Additionally, 60 per cent of outpatient visits and 30 per cent of hospitalisation cases are attributed to malaria. A study estimated that one in four of the global cases of malaria occurred in Nigeria.

The World Malaria Report indicated that Nigeria and four other countries account for nearly half of the global malaria cases. Among these five countries, Nigeria has the highest cases; with 25 per cent, followed with 11 per cent by the Democratic Republic of Congo, five per cent by Mozambique, and four per cent each in India and Uganda.

For a disease that causes thousands of deaths in a year, especially in low- and middle-income countries, elimination will be a groundbreaking feat.
According to the WHO, for a high-burden country like Nigeria, elimination is believed to be not only challenging but near impossible. However, WHO states that it can become a reality if a high-burden country works to enhance and optimise malaria prevention and treatment measures as well as strengthen their malaria surveillance system.

What is Being Done?

Malaria control programmes date back to 1948 in Nigeria, with the National Malaria Service. Presently, the country is running a National Malaria Elimination Programme, which started in 2013. The focus of the programme are:

i) Access to long-lasting insecticide-treated mosquito nets (LLINs)
ii) Indoor residual spraying (use of insecticides)
iii) Management of mosquito larva
iv) Administering intermittent preventive treatment in pregnant women (IPTp), and
v) Vector sentinel surveillance and resistance monitoring and quality assurance of commodities.

The objectives of this programme are further clearly outlined in the 2014 – 2020 National Malaria Strategic Plan, which it aims to achieve by 2020:

I) 80 per cent of Nigerians to use one form of preventive method or another
2) To test every sick person suspected of having malaria with Rapid Diagnostic Test (RDT) kits or microscopy test.
3) To treat every sick person with confirmed malaria in private or public hospitals with an effective antimalarial drug.
4) To provide information to all Nigerians such that 80 per cent of the population routinely takes malaria prevention and treatment measures.
5) To ensure that by 2018, all commodities for prevention and treatment are available wherever they are needed on time.
6) 80 per cent of facilities in the LGAs report routinely on malaria, to use this data for further planning.
7) To achieve an ‘A’ rating on the set scorecard on these set goals through the efforts of all stakeholders starting from 2017 through 2020.

These targets are a carryover from the 2009 – 2013 Roll Back Malaria (RBM) Plan.
Overall, the RBM plan saw 53 million insecticide-treated nets distributed with national average ownership of 42 per cent. Indoor residual spraying trials were introduced in three local government areas in seven selected states of Bauchi, Jigawa, Gombe, Kano, Anambra, Akwa-Ibom and Rivers through the World Bank Malaria Booster Programme.
The plan also achieved:

i. Coverage of 250,000 households from 2009 – 2012 in Lagos through the Lagos Ministry of Health, and in selected areas in Nasarawa state by the US President Malaria Initiative in 2011.
ii. Introduction of pilot larviciding (insecticides sprayed in the environment to kill the larva stage of mosquito) in five states of Rivers, Nasarawa, Ogun, Lagos and Jigawa, with the aim of initiating its wide use. But this is only being practised in Lagos and Rivers with shallow coverage.
iii. Increase in testing for malaria in patients presenting to clinics with fever from an average of 15 per cent to 39.8 per cent nationally, using RDT kits. Artemether-Lumefantrine and Artesunate-Amodiaquine are the recommended ACTs (artemisinin-based combination therapy) for the treatment of uncomplicated malaria in Nigeria. Their use, although increased, was only 47.5 per cent of the recommended 569.9 million doses required between 2007 and 2013, for instance. Within this same period, prompt treatment of children with ACT was reported as 7.8 per cent in the urban areas, and 2.1 per cent in the rural areas (i.e a little above zero chance of a child out of 10 children receiving prompt ACT).
iv. IPTp showed a wide difference between the states, averaging at 18.7 per cent coverage, moving along with antenatal care (ANC) attendance.

The RBM plan reported that it achieved less than half of the targets in most of its set objectives. Programme review at the end of the period, 2009 – 2013, noted the challenges. Major among them are:
1. Most implementation successes resulted from the significant support from donor agencies, bilateral and multilateral implementation partners.
2. Low utilisation of LLINs as even ownership stood at less than 50 per cent across the country.
3. Relatively low level of testing and available testing kits.
4. Low IPTp coverage, and
4. No proper vector management in most communities.

It would seem that despite this being Nigeria’s burden, the country has not been investing as it should in the fight against malaria. The WHO 2018 report shows a decline in funding for the period 2012 – 2017.

Intervention programmes are mostly donor driven as depicted by the indoor residual and larval control trials, after which local governments do not expand and carry on projects.
No local factories at the moment manufacture LLINs, while most of the ACT are still imported. Also, the non-inclusiveness of proper environmental waste and drainage control with vector management shows no serious intent towards mosquito control.

A review of the programmes implemented in Nigeria indicates some form of progress has been made towards malaria elimination in the country. However, the question of whether elimination is achievable and sustainable in the country depends on the commitments to the preventative strategies laid out, as well as funding and research and developments.
Most recently, the news of a landmark programme of a malaria vaccine in the works in Malawi brought hope to the cause in Africa. But again, Nigeria is not at the forefront of this vaccine development despite its burden with this disease.