Malaria: Will it Ever Go Away?

THISDAY Newspaper

T he fever of the World Malaria Day commemorated earlier in the week on April 25 is still very palpable. Activities were organised nationwide to mark the day and these provided another opportunity to take a balance sheet on the effect of the various interventions put in place to curb the malaria scourge that is endemic throughout Nigeria. According to the statistics presented in the recently released 2008 Nigeria Demographic and Health Survey (NDHS 2008), malaria currently accounts for nearly 110 million clinically diagnosed cases per year, 60 percent of outpatient visits, and 30 percent hospitalisations in Nigeria.

An estimated 300,000 children die of malaria each year. It is also believed to contribute up to 11 percent maternal mortality, 25 percent infant mortality, and 30 percent under-five mortality. Aside the direct health impact of malaria, the social and the economic cost on communities and the country as a whole is enormous, with about 132 billion Naira lost to malaria annually in the form of treatment costs, prevention, loss of work time, school absenteeism amongst others.

This year’s world malaria day is an opportunity to assess the full impact of the National Malaria Control Strategic Plan (NMCSP), which was set up to address the national health and development priorities including the Roll Back Malaria (RBM) Goals and the Millennium Development Goals (MDGs).

The NMCSP includes the following priorities: to reduce malaria related
mortality, to reduce malaria parasite prevalence in children under five, to increase ownership and use of insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs), to introduce and scale-up indoor residual spraying (IRS), to increase the use of diagnostic tests for fever patients, to improve appropriate and timely treatment of malaria, and to increase coverage of intermittent preventive treatment (IPT) of malaria during pregnancy. The NMCSP lays out specific targets to be achieved by 2010 and sustained through 2013.

The point, however, is to ask how far are the targets being met? For an example, the World Health organization (WHO) had noted that use of insecticide-treated nets is the most cost-effective method of malaria prevention in highly endemic areas like Nigeria. The use of insecticide-treated nets (ITNs) or long-lasting insecticidal nets (LLINs) is the main method of malaria prevention employed in Nigeria. To this extent, free distribution of long-lasting insecticidal nets (LLINs) is conducted through campaigns, public health facilities, faith-based organisations (FBOs) – churches, mosques, and non-governmental organisations (NGOs) with the goal of achieving universal access for the at-risk populations of children under age five and pregnant women. Beyond the aforementioned however, we need to find out what the distribution spread of these nets are like and more importantly what is the usage compliance like? Are the individuals who collected the nets using the nets as prescribed or using it at all. If so, what are the limiting factors against these anticipations?

The earlier mentioned survey report (2008 NDHS) made some attempts to verify and answer some of the noted posers above. All households in the 2008 NDHS were asked whether they own a mosquito net and, if so, how many. The results indicated that 17 percent of households in Nigeria own a mosquito net (treated or untreated), and 8 percent of households own more than one mosquito net. The percentage of households that own at least one ITN is 8, while 3 percent own more than one ITN. The average number of ITNs per household is however less than one, meaning that a high majority of Nigerian households are not effectively covered with the usage of insecticide-treated nets.

Other important findings are that 12 per cent of children under age five slept under a mosquito net on the night before the survey. The same proportion slept under an ever-treated net; however, only 6 percent of the children slept under an ITN. It is interesting to note that only half of children in households that own an ITN slept under an ITN on the night before the survey. The use of any net, an ever-treated net, and an ITN decreases with increasing age of the child. The percentage of children who slept under an ITN on the night before the survey increases with wealth quintile. In other words, the rich seems to see more sense with the children using the insecticide-treated nets; or it could be that the harsher clime (crowded living abodes and uncontrollable hot environment) of the poor segment of the society discourages the use of these nets.

Comparing the trends of ownership of Insecticide-treated net (ITN) in the last five years, between the 2003 and the 2008 Nigeria Demographic and Health Survey, it was revealed that all net coverage and use indicators have increased between the two surveys. The percentage of households that own any type of net increased from 12 percent in 2003 to 17 percent in 2008, while ownership of an ITN increased from 2 percent to 8 percent. The proportion of children under age five who slept under a mosquito net on the night before the survey doubled in the period between the two surveys from six per cent to 12 per cent.

The proportion of children sleeping under ITN increased from one per cent to 6 per cent. The percentage of pregnant women who slept under any net and under an ITN on the night before the survey showed improvements similar to those observed for children under age five. However, notwithstanding these improvements, they still fall short of the expected targets as per spread and usage of the all important preventive tool – Insecticide Treated Net (ITN)

Similarly, the trend in the use of anti-malaria medication to prevent malaria in pregnancy was also assessed by the 2008 NDHS. This is against the background that pregnant women who carry the malaria parasite may be at risk for serious problems that jeopardise their own health, compromise the health of the unborn baby, and increase the likelihood of adverse pregnancy outcomes such as stillbirth, spontaneous abortion, and low birth weight.

As a protective measure, nine years back (2001) the Federal Ministry of Health recommended that pregnant women receive Intermittent Preventive Treatment (IPT) of malaria during pregnancy using two doses of sulphadoxine-pyrimethamine (SP). Among the common brands of SP in Nigeria are Fansidar, Amalar, and Maloxine. In accordance with the national protocol, SP is given free of charge to pregnant women through ANC services at public health facilities and non-governmental organisation (NGO) facilities. Using an approach of directly observed therapy, one dose of SP is given twice, spaced by at least one month interval, during the last six months of the pregnancy. A third dose is however recommended for pregnant women who are HIV positive.

According to the 2008 NDHS, 18 percent of women received an anti-malarial drug for prevention of malaria during the pregnancy for their last live birth in the two years preceding the survey. This figure is a little less than the percentage reported in the 2003 NDHS (20 percent); although, compare to the 2003 NDHS, there has been an increase in the coverage of SP as IPT from 1 percent to 8 percent. The survey also collected information on the number of doses of SP taken by pregnant women. Overall, 11 percent of pregnant women reported receiving at least one dose of SP to prevent malaria during pregnancy and 7 percent of pregnant women received two or more doses.

Another important related finding in the survey is the assessment of the general attitude of the populace to using the WHO recommended anti-malaria drugs - the new Artemisinin-based Combination Therapy (ACT), which was introduced in 2005 - to treat uncomplicated malaria in under-five children. Malaria have been previously noted to have become resistant to the traditional medications especially the old reliable chloroquine. The 2008 NDHS however revealed that more children are still being treated with the WHO-relegated anti-antimalarias i.e. chloroquine etc than are treated with the recommended ACT for first line treatment of malaria.

With the above taken into consideration; then, it’s not difficult to deduce that, although some progress have been made in the war against malaria in the context of prevention and prompt treatment with effective medications, we are still far from the outlined targets and the related goals. It will take much more than it is presently being done to put malaria behind us.


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