The Global Burden of Malaria Disease: The Evaluation of the Progress, Challenges and Recommendations towards Malaria Control and Prevention in Nigeria
ACT- Artemisinin-based combination therapy
GDP- Gross Domestic Product
ITN – Insecticide-treated Nets
IRS – Indoor Residual Spraying
LLIN- Long-lasting Insecticidal Nets
NMSP- National Malaria Strategic Plans
NMIS- Nigeria Malaria Indicator Survey
RDT- Rapid Diagnostic Testing
WHO- World Health Organization
Malaria is a mosquito-borne disease caused by parasites in the Plasmodium family and transmitted through the infected bites of female Anopheles mosquitoes(1-3). Though preventable and treatable, more-than-half of the world’s population is at risk of malaria(1). Malaria affects World Health Organization(WHO) regions in the Eastern-Mediterranean, Western-Pacific, South-East Asia and the Americas with the greatest impact occurring in sub-Saharan Africa(1). In 2013, around 3.2billion individuals were at risk in 97 counties and territories where approximately 198million cases of malaria occurred, killing over 580,000 people(3). According to 2017 World Malaria Report, 216million cases of malaria was reported in 2016, an increase of 5 million cases from 2015(211 million cases)(1, 4). The global estimate of deaths caused by malaria in 2016 was 445,000, a thousand less than 2015(1, 4).
Epidemiology and Burden of Malaria
The WHO Africa region contributes to an excessive share of the global burden of malaria(1), accounting for 90% of cases and 91% of deaths worldwide in 2016(1, 4). About 80% of the global disease burden is shared among 15 countries, 14 in sub-Saharan Africa and India(1, 4). Approximately 90% of all malaria deaths occur in the Democratic Republic of the Congo and Nigeria, resulting in 40% of malaria mortality rate globally(3). Malaria remains a major endemic in Nigeria(5) accounting for 25% of the worldwide cases and deaths(2). It is considered the second infectious disease causing death in Africa following HIV/AIDS(6). It is the leading death among children under-5(20%), constituting for 10% of the disease burden in Africa(6). It is a risk for 97% of the population, causing more deaths in Nigeria than any other country(2, 7). Roughly, 100million cases of malaria and over 300,000 deaths occur annually in Nigeria, compared to 215,000 deaths from HIV/AIDS(2).
Distribution of Malaria among Population at Risk
Malaria causes an overwhelmingly negative effect on human health and livelihood globally(3). Certain groups have a higher risk of contracting and developing malaria disease than others(1). These vulnerable groups are children under-5years, pregnant women, travellers and people with HIV/AIDS(1, 8, 9). Malaria is the third major cause of death among children under-5years globally(6, 10), with 1 in 5 deaths in children under-5 occurring in Africa(10). Nigeria has the highest malaria prevalence among children aged 6-59 months; accounting for 50% of child deaths in the South-West, North-West and Northern regions, and contributing to 11% of the maternal(10), 25% of infant and 30% of under-5 mortality rate in the country(11). Approximately 110million clinical diagnoses and 300,000 child deaths occur each year from malaria(11). Individuals that live with HIV/AIDS are also at high risk of suffering from clinical malaria disease(10). This double burden heightens viral load in HIV-infected patients, increasing the occurrence of mother-to-child transmission, and worsening their health outcome(10). Malaria overburdens the health system in Nigeria and applies great social and economic strife in the country, impeding gross domestic product(GDP) growth by 40% annually(11).
Socio-cultural and Economic Impacts
In countries that suffer from malaria-endemic, the ailment disproportionately affects underprivileged and poor populations with inadequate access to healthcare and means to fund recommended treatments(3). Research has found that where malaria prospers the general population does not, this correlation implies that malaria and poverty are correlated(12). A study comparing the GDP of countries with higher cases of malaria to non-malaria prone countries reported an average GDP growth of 0.4% per year compared to 2.3% respectively(12). Poverty can be held responsible for the promotion of malaria transmission and likewise, malaria can lead to poverty by hindering economic development. Causality may apply in both directions, especially in the poorest countries(12, 13). From 1999 to 2004, the distribution of malaria showed a significant decrease in high populations outside of Africa, while an increase from 0.06 billion to 0.65billion occurred in Africa(13). In Nigeria, approximately 65% of the people live in poverty, contributing as a key factor in malaria spread(10).
Malaria impedes direct foreign investments in endemic countries, restricts internal movement of individuals and goods due to weak infrastructure(13). The economic burden associated with malaria also incapacitates the workforce through high medical costs(13). This is seen in both private and non-private health costs and loss of wages resulting from malaria mortality and morbidity(12). Private health costs include individual expenditure of diagnosis and treatment of the disease like doctors visit, purchase of bed nets and antimalarial drugs, transportation(12), school absence, and burial costs(9). Non-private health costs include government expenditures on health facilities, research, vector control and education(9, 12). The direct cost of malaria disease, treatment and premature deaths is nearly $12billion dollars a year(9). About 60% of outpatient visits and 30% of under-5 hospitalizations yearly are attributed to malaria in Nigeria(5, 10). The economic burden in Nigeria reported in 2011 due to malaria was approximately N132 billion Naira(5) which increased to N480 billion Naira in 2014(11) from treatment costs, prevention and man-hours(5) and out-of-pocket expenditure(11).
Causative factors of Malaria
Malaria is caused by the Plasmodium parasite and transmitted by night-biting female Anopheles mosquitoes(1-3, 8). The dominant mosquito vector species in Nigeria are Anopheles gambiae and the A. funestus(11). There are five parasite species that cause malaria in humans; P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi(2, 14, 15). P. falciparum is the most common and dangerous malaria parasite, mainly found in Africa and responsible for the greatest death globally(14). P. vivax is found in South-America and Asia, it presents milder symptoms than P. falciparum and remains active in the liver for up to three years(14). P. ovale is found in West-Africa and lies dormant in the liver for years without presenting symptoms(14). P.malariae and P. knowlesi are both rare to contract and found in Africa and Southeast-Asia respectively(14). The most prevalent parasite species in Nigeria is the P. falciparum accounting for more than 95% of malaria cases in the region(11). P. ovale and P. malariae are also found in minor cases in Nigeria, with P. malariae infections isolated to children(11).
Malaria is directly spread from the bite of an infected mosquito, where the parasites living inside the gut and salivary glands of the mosquito are injected into the host/human bloodstream infecting the liver and blood cells(8). In rare occurrences, malaria can be transmitted from person-to-person through blood transfusion, infected needles and from mother-to-fetus(8). Once infected, the following first symptoms present themselves within 7 days; headache, chills, vomiting, and fever(1, 2, 16). If not treated, the disease can cause more severe symptoms like anemia, metabolic acidosis and cerebral malaria, especially in children(1).
Malaria transmission intensity is increased in regions that support long mosquito lifespans(1) and is dependent on factors that influence the parasite, vector, human host and environment(2). Around 90% of malaria cases globally are centered in Africa due to the long lifespan and human-biting preference of the P. falciparum(1). Mode-of-transmission is also dependent on environmental conditions like temperature, moisture and rainfall patterns that influence the survival of mosquitoes(1, 2). Nigeria is seasonally tropical and humid and its environmental conditions make it ideal for recurrent malaria transmission. About 30% of the population resides in high-transmission areas and almost 70% live in a moderate-transmission zone(11). However, recent reports revealed that 85% of individuals living in Nigeria, reside in regions of moderate-transmissions and about 15% currently dwell in high-transmission areas(11). This highlights the deviation of in-country differences in malaria endemic, with high transmission appearing in the states of Adamawa, Borno and Abuja (11). The duration and intensity of malaria transmissions adjust according to climate types, which are distinct from the Southern to Northern regions of Nigeria(11).
Malaria endemics are more likely to occur in climates that encourage transmission in regions among populations with low-resistance to the disease, and when individuals with low-immunity relocate to regions with concentrated malaria transmission(i.e. travel, work, refugees)(1, 2). Human resistance to malaria is an important factor especially among adults in high-to-moderate transmission conditions(1). Partial resistance may develop from years of exposure and limit the severity of an infection(1). This results in the trend of malaria deaths in Africa occurring significantly among young children, while all age groups in other regions with low-transmission and resistance to malaria are equally at risk(1, 2).
Malaria Prevention Measures
The key measure to preventing and limiting the transmission of malaria is through vector control(1). If adequate vector-control interventions are in place, they provide a prevention measure that protects the population(1). Two forms of vector control are insecticide-treated mosquito nets(ITNs) and indoor residual spraying(IRS)(1, 7). These methods have proven to be effective in diverse circumstances(1). Long-lasting insecticidal nets(LLINs) are the recommended type of ITNs for malaria preventions programs(1). They effectively prevent malaria for at least 4 years and a minimum of 20 washes(17). Offering LLINs at no cost to communities in need is the most effective way to guarantee equal access to all(1). In addition, active behavioral strategies are needed to encourage at-risk populations to utilize LLINs daily, safely stored and maintained LLINs after use(1). IRS using insecticides is an alternative method for rapid reduction of malaria transmission(1). Based on the insecticide formula used and surface treated, IRS protection is effective for 3-6 months when 80% of the targeted area is treated (1).
In some cases, IRS can be used as a form of protection within a community for an entire malaria season(1). Antimalarial medications are another form of protection from malaria, within various groups(1). Among travellers, chemoprophylaxis is used to suppress the blood stage of malarial infection, inhibiting disease formation(1). For pregnant women in Africa, residing in moderate-to-high transmission areas sulfadoxine-pyrimethamine is recommended after the first trimester at intermittent doses during antenatal visits(1). For infants in high-transmission regions of Africa, three doses of sulfadoxine-pyrimethamine are recommended during routine vaccinations(1).
Malaria Control Challenges in Nigeria
The lack of sustainable international funding, political commitment, and maintained global collaboration has contributed to the current worldwide challenge of eradicating malaria(3). The rise of drug and insecticide resistance; weak health and surveillance systems, poor monitoring and evaluation programs, have hindered efficient malaria response, eroding the efforts towards improving disease burden and building sufficient healthcare resource capacity(3). The key challenges to malaria control and intervention in Nigeria include behavioral practices that contribute to mosquito breeding, under-utilization of effective treatments among at-risk populations, and non-behavioral factors like geographic, tropical and environmental conditions, availability and presence of mosquitos and parasites(6). Other active contributors to the resurgence of malaria in Nigeria include; recurring conflicts, poverty, miseducation about malaria, and lack of access to quality drugs and health facilities(6).
Anti-malarial Drug Resistance
Drug resistance is the main challenge in the battle against malaria(18). In the 1980’s chloroquine drug resistance resulted in malaria endemic across countries worldwide. A rapid resistance of malaria parasites to chloroquine, supplementary quinolones(6) and Sulphadoxine-pyrimethamine(5) was reported in Nigeria. Prior to that, chloroquine was the recommended drug against malaria and has since given rise to Artemisinin-based combination therapy (ACT)(18). The ACT has played a significant role in diminishing deaths caused by malaria in the last decade(18). However, Artemisinin-resistant P. falciparum parasite has gradually spread throughout southeast-Asia and threatens malaria control globally(18). An increase in artemisinin-resistant parasite has been reported in numerous countries in Africa with insecticide-treated nets losing effectiveness in 41 counties globally and 27 countries in Africa(6). These resistant parasites threaten the progress of malaria control in Nigeria(6). Factors that aid in the function of drug resistance includes inaccurate dosing, drug non-compliance with regimen duration, inadequate drug quality and misdiagnosis(18). Similarly, in Nigeria, antimalarial resistance cases have been associated with inaccurate drug dosage and non-compliance(5). Some malaria treatments are administered at home, among rural dwellers in which a decent proportion have limited reading proficiency, resulting in non-compliance with dosage delivery instructions and inappropriate use of antimalarial medicines(5).
Insecticide-Treated Nets(ITN), Use and Resistance
Data on insecticide resistance was collected from 2010-2016. Of the 76-malaria endemic countries that reported data, 61 countries indicated resistance to one insecticide, and resistance to two or more insecticide was reported in 50 counties(4, 19). By 2016, all WHO regions reported one or more cases of insecticide resistance(4). Built resistance to pyrethroids insecticides presently used in ITNs is actively prevalent(4). Among malaria-endemic countries that monitored pyrethroid-resistance, 71% reported resistance in 2010, with an increase of 10% in 2016 (81%)(4). Confirmed resistance differ among regions, with the greatest resistance in WHO Eastern-Mediterranean and Africa region, where resistance to pyrethroids was detected in malaria vectors in more than two-third of monitored sites(4). 27 countries in sub-Saharan Africa reported pyrethroids-resistance(10). Anopheline vector resistance to pyrethroids has been reported in Nigeria(18). The rising development of pyrethroid-resistance in African-tropical malaria vectors will impede the success of ongoing malaria control interventions(18). Additionally, problems with the distribution, use and acceptance of ITNs in Nigeria has hindered the progress of malaria control(6). The Nigeria Demographic and Health Survey on malaria prevention measures found that only 17% of households had at least one mosquito net, while less (8%) own an LLIN, indicating the lack of LLIN utilization in Nigeria(6). Economic status, alternative barriers, unavailability, skin reaction, and unawareness, all affect the widespread of ITNs in Nigeria(6).
Conflicts, Migration and Internally displaced persons
The movement of non-immune individuals across countries with malaria infested regions is one of the effects of civil wars(18). Refugees, internally displaced persons, and returnees threaten malaria control efforts and strain weakened health systems from civil conflicts and undermine progress made(18). Additionally, armed conflict creates deteriorated environments with poor sanitation that breed malaria vectors and restrict access and delivery of medical supplies to surviving populations(6). Nigeria is presently effected by conflicts, terrorism, migration and internally displaced populations across all regions with the northeast facing the greatest burden(18).
Knowledge and Attitude on Causes and Control of Malaria
Understanding malaria illness, causes, modes-of-transmission, the seriousness of illness, preference and decision-making on preventive and control measures differ among individuals, households and communities(18). Misconceptions about malaria, disease control, and treatment still exist(6, 18). For instance, in Nigeria, residents of urban and rural areas in Benue state reported beliefs that malaria is attributed to spirits, charms, stress and malnutrition(6). These perceptions contribute to the socio-cultural shortfalls in malaria control and add to the divergences in health seeking behavior, delaying or preventing proper malaria treatment(6).
Financial investment is necessary to eliminate, prevent and support the worldwide eradication of malaria(18). Malaria prevention funding in Africa in the past decade has yielded significant impact in the reduction of malaria incidence(18). These benchmarks were achieved with the support of international and domestic investments in malaria prevention(18). However, aid funding has bred dependency among beneficiaries(18). This has contributed to the continued decline in malaria eradication as international funds are often time-limited and unsustainable(18). Therefore, should aid cease, dependent countries are unable to fund the established malaria control interventions, resulting in a setback on achievements made(18).
Nigeria’s National Malaria Control Approach
In the past two decades, Nigeria has implemented three National Malaria Strategic Plans(NMSPs) and is currently in its fourth plan(11). The plans are as follows: Build partnerships and gather political will, which was developed following the Africa Summit on Roll Back Malaria from 2001-2005(11). Target and address at risk populations for primary interventions, from 2006-2010(11). Establish universal, equitable access and rapid provision of core interventions, as a road map for malaria control from 2009-2013(11). Decrease malaria-related deaths to zero by 2020 by achieving pre-elimination status(<5,000 cases per 100,000 persons) from 2014-2020(11, 20). The core objectives for the current 2014-2020 7-year NMSP interventions are:
Deliver appropriate preventive measures to 80% or more of the targeted population:
This involves expanding universal access to ITNs by providing mass distribution of LLINs, increasing application of IRS and management of larval environmental sources. Active support of preventive intermittent therapy in pregnant women and seasonal malaria chemoprevention has also been implemented(11, 20).
Using rapid diagnostic testing(RDT) or microscopy to test all care-seeking individuals with suspected malaria: This is achieved through a substantial increase in available facilities for parasitology testing using RDT/or microscopy at all levels, including private and community health systems. Policies will be enforced to ensure the diagnostic product(11, 20).
Use effective antimalarial drugs to treat individuals with confirmed malaria infection in private and public facilities: Employing free, subsidized and commercial systems to promote and ensure the availability of effective antimalarial drugs are being developed. Community-level interventions will provide pre-referral treatment and better-quality referral systems, while secondary and tertiary health facilities will be enhanced and equipped to deliver treatment objective for severe cases of malaria(11, 20).
To educate all Nigerians, equipping at least 80% of the population to take appropriate preventative and treatment measures of malaria: To attain this objective, evidence-based behavioral change communications are disseminated in various platforms targeting health workers, at-risk, and general populations. Additionally, advocacy targeting policy-makers, stakeholders and social mobilizers will be vastly promoted(11, 20).
Ensure a well-timed availability of appropriate antimalarial medications and supplies for prevention and treatment of malaria across Nigeria: The efficiency of medication distribution systems will be strengthened by empowering government agencies to implement and update malaria-related regulation policies and conduct antimalarial medication vigilance(11).
Routine reports on malaria among 80% of health facilities in all local government: The use of short message service(SMS) to transmit information from peripheral facilities to central health systems is being introduced. To ensure complete reporting of malaria cases from health facilities, strong supervision and coordination practices are enforced and enhanced. To guide the scheduling of data collection, a massive monitoring and evaluation framework has been developed and deployed(11, 20).
Strengthen governance and coordination among stakeholders for effective program implementation: Build on current partnerships to continue promotion and investments in human capacity development, availability, access, and use of antimalarial drugs and supplies while and increasing governance commitments(11).
Recommendations on Public Health Response to Malaria
Since the inception of the NMSPs, Nigeria has developed and implemented thorough initiatives addressing malaria control, which has resulted in attaining target milestones(5). To prolong the improvement of malaria prevention and control, dedicated financial investments, committed governance, improved health infrastructure and sustainable public health interventions are essential. Emphasis should be placed on current programs and strategies Nigeria has in place to combat malaria, strengthening its preventative measures by eliminating behavioral, environmental contributors and educating communities on lifestyle changes to reduce malaria incidence.
Malaria disease control can be assessed from a research method perspective. In 2015, the Nigeria Malaria Indicator Survey(NMIS) was conducted as a baseline qualitative survey to access achievements of the NMSP and provide information on malaria indicators and prevalence nationally and within all 36 states and the Federal Capital Territory(11). The key aims were to; assess extent of ownership and use of ITNs, coverage of preventive treatments among pregnant women, current practices for malaria treatment in children under-5, use of antimalarial drugs, prevalence of malaria and anemia in children aged 6-59 months and measure knowledge and attitudes towards malaria preventive practices in the general population(11). Household questionnaires obtaining data on water, sanitation, dwelling environment and ITNs use, women’s questionnaire on knowledge, antenatal care and malaria prevention history, and biomarker questionnaire on malaria testing using RDTs were collected from respondents(11). This survey found that 49% of pregnant women aged 15-49 slept using an ITN and 37% had two or more doses of sulfadoxine-pyrimethamine, receiving at least one during their antenatal visit (compared to 13% in 2010)(11, 21, 22). The study also indicated that 44% of children under-5 slept under an ITN and 27% tested positive for malaria by RDT/ or microscopy testing, a 15% decline from 2010(42%)(21, 22).
The fight against malaria has been long-drawn-out in Nigeria, however to fast-track the progress towards malaria control and elimination, epidemic preparedness and response, increased research towards vaccine formation, policy formulation(5), entomological surveillance(3) are recommended in addition to maintaining standards for on-going interventions.
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