[Effects on Health] Facts on malaria in Africa

from The Tide Nigeria

A paper presented by the federal Ministry of Health (FMOH) during the Africa Malaria day celebration at Abuja, recently.

Introduction: Malaria is a parasitic disease which is easily preventable, treatable and curable. However, it remains one of the major public health problems in Nigeria (FMOH 2000). The malaria burden as reported in the country is on the increase in spite of numerous interventions that have been instituted. The obstacles to the success of these interventions are socio-cultural, economic and political in nature.

Malaria is caused primarily by Plasmodium species of various types: P. Falciparum; P. ovale, P malariae, P vivax. Plasmodium falciparum which is the commonest in Nigeria, causes most severe malaria illness and death throughout the world (WHO 1998). Plasmodium falciparum is known to be the most devastating in Nigeria. The transmission of the plasmodia is facilitated through the bite of the vectol; female Anopheles mosquitoes.

Two broad categories of predisposing factors are implicated in the prevalence of malaria in Nigeria. These are behavioural and non-behavioural factors. The behavioural factors relate to some cultural practices that promote mosquito breeding and access of mosquitoes to the people as well as the failure of vulnerable populations to use proven and effective interventions for the treatment, control and prevention of malaria. The main non-behavioural factors include geographical or ecological peculiarities such as tropical (warm) climate and vegetation that promote breeding and sustenance of mosquitoes and the causative agents, the Plasmodium species.

Malaria situation in Nigeria

Malaria is a major cause of morbidity and mortality in Nigeria (FMOH 2000). It is endemic throughout the country with seasonal variation in different zones of the country. At least, 50% of the population suffers from at least one episode of malaria each year. The disease is the commonest cause of outpatient attendance across all age groups.

Some categories of people are however, at highest risk of infection. These include children aged less than 5 years, pregnant women, visitors from non-malarious regions and people with sickle cell anaemia. The Federal Ministry of Health has noted that malaria leads to 25% of infant mortality and 30% of childhood mortality.

The result of the most comprehensive study of the malaria situation in Nigeria conducted across the six geographical zones in Nigeria have signified the public health importance of malaria (FMOH 2001). The study confirmed that malaria is a major cause of morbidity and mortality especially among vulnerable groups including women and children aged less than 5 years. The incidence of malaria among the under fives across six geographical zones during the study were as follows: South-South 32.7%, South West 36.6%, South East 30.7%, North Central 58.8%, NorthEast 55.3% and North West 33.6%.

It was also found that malaria often occur as a co-morbid condition with some other prevailing health problems. Furthermore, it was found that malaria accounted for 11 % of maternal deaths in the study areas. Malaria also accounted for 63% of the diseases reported in healthcare facilities across the six geographical zones. The prevalence of malaria among pregnant women was 47%.

Malaria constitutes a major economic burden on endemic communities in Africa, including Nigeria. It costs sub-Sahara African countries including Nigeria, more than US$12billion in 1997 (WHO 1998). Malaria is implicated in the reduction of human work capacity and productivity (GFFHR 2000). Consequently, it adversely affects the socio- economic development of the nation (FMOH 2001, GFFHR 2000). The disease thus constitutes a great burden on the already depressed Nigerian economy (Netmark,2001a). The high rate of absenteeism among school children in Nigeria is attributed in part to malaria (Gbadesin 2001; GFFHR 2000). Malaria causes a lot of misery to sufferers, and adversely affects the social and psychological well being of individuals, families and the nation at large. It can also sabotage the investment drive efforts of the Government through negative impact on tourism especially during high transmission seasons.

Home Management of Malaria in Nigeria: The National survey conducted by the Federal Ministry of Health in 2001, showed that home management of malaria in children aged less than 5 years was veT)’ common in both communities with or without healthcare facilities. Care provided at home and community ranked first in the actions taken during illness in under fives. Under-five caregivers visit a variety of sources such as patent medicine vendors, traditional healers, health centres, hospitals, private clinic, drug hawkers and diviners to obtain medications.

Another study carried out in Southwest Nigeria confirmed that home management of childhood malaria is very common (Adeniyi et aI, 2000). It also showed that 85% of caregivers did not buy drugs from hawkers because of their lack of confidence in them. A total of 16.6% of childhood malaria were referred to hospitals because of persistence of symptoms. Caregivers currently use variety of drugs for the management of childhood malaria. Many of the drugs used were found to be inappropriate based on national policy.

Malaria and Pregnancy According to the Africa Regional Office of WHO, in areas of high and moderate (stable) malaria transmission, malaria infections in pregnant women contribute to development of severe anaemia in the mother, resulting in an increased risk of maternal mortality. The impact on the fetal well- being and child’s health results from maternal infection mainly during pregnancy.

Malaria infection of the placenta and malaria-caused maternal anaemia contributes to low birth weight (LBW), which results in higher infant mortality and in impaired child development. WHO recommends a three-pronged approach, use of intermittent preventive treatment (IPT), insecticide treated nets (ITN), and effective case management of malaria illness to reduce the burden of malaria infection in pregnancy. In most stable transmission countries of Africa, more than 70% of pregnant women attend antenatal clinic (ANC) at least once during their pregnancy, making a clinic based prevention approach feasible.

Use of Insecticide Treated Nets: The efficacy of Insecticide Treated Nets (ITNs) was first tested in Nigeria in 1992-94 by the Federal Ministry of Health in collaboration with the US Centre for Disease Control and Prevention (CDC) in rural communities outside Nsukka, Enugu State. The positive results led to calls for practical implementation of ITN programs throughout the federation. The hosting of the African Summit on Malaria in Abuja in 2000 provided impetus for local programming to begin. In consonance with the relevant Abuja targets, the objectives for ITN programmes in Nigeria include the following: . 60% of parents (or caregiver) to ensure that their children below 5 years of age sleep under ITNs every night . 60% of pregnant women to sleep under ITNs nightly.

Studies have shown that the use of ITN is generally low in Nigeria among all categories of people. It was observed that only 12% of households in Nigeria reported owning mosquito nets (Netmark, 2004) and 16% in 2005 (FMOH, 2005). Briegeret all 996 also observed in a study conducted in Nsukka that altogether, 22% of the survey respondents reported, that mosquito nets had been used before by a member of their household. In some isolated cases, people are willing to pay for the nets. Willingness to pay for bed nets and insecticides for treating them was found to be high in four communities in Eastern Nigeria (Onwujekwe et aI, 2000). In another study, Onwujekwe et al (2001), noted that about 3 9%.of their respondents were willing to pay for mosquito nets and actually redeemed their pledges.

The most recent study on use of ITN was by the National Demographic Health Survey (NDHS) 2003, which revealed that 12% of all households own at least a net (any type) while only 2% use at least one ITN. The result also showed that ownership of nets (either any type or ITN) is significantly higher among the rural dwellers than those living in urban areas. There is also a wide variation of net ownership across the six geo-political zones with more nets being available among the households in the North (except North East) than the south.

Change in Malaria Treatment Policy: A major intervention for malaria control proposed by Roll Back Malaria is the provision of effective, affordable, acceptable and available anti-malaria drugs to enhance prompt and appropriate treatment of malaria episodes within 24 hours of onset of illness (FMOH 2002). However, increasing parasite resistance to the anti-malaria drugs has emerged. This calls for the continual evaluation of the efficacy of these medicines in order to inform decisions on malaria treatment policy.

Until recently, Chloroquine and Sulphadoxine Pyrimethamine were the first line and second line drugs for treatment of malaria. In 2002, the Federal Ministry of Health, with the support from the World Health Organisation, conducted the Drug Efficacy Testing (DET) in six sites covering the six geo-political zones of the country, using approved WHO protocol. The studies were conducted to update the National Anti-Malaria Drug Policy and to determine the efficacy of the first line (CQ) and second line (SP) drugs for the treatment of uncomplicated malaria in the country.