INTRODUCTION
Malaria is a disease spread by the female Anopheles mosquito and is caused by a parasite known as Plasmodium. The mosquito carries the parasite and is where the parasite starts its life cycle. Once the parasites get into the human body, they travel to the liver where they mature. After several days, the mature parasites enter the blood stream and begin to infect the red blood cells. Within 48-72 hours, the parasites inside the red blood cell multiply causing the infected cells to burst open usually resulting in development of symptoms like chills, headache, vomiting, fever and so on. Malaria is not a communicable disease but can be spread without a mosquito example, through blood transfusions. The subspecies of Plasmodium include Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, and Plasmodium knowlesi.
Malaria remains the most important public health parasitic disease and a major global health problem with the greatest burden in Sub-Saharan Africa. Nigeria accounts for 25% of the world’s malaria burden. Apart from the health burden, the socio economic consequences are enormous such that it was part of the Millennium Development Goals and Goal 6C was to halt and reverse the incidence of malaria by 2015. Following the end of the Millennium Development Goals, the WHO member states, Nigeria inclusive, on 20th May, 2015 agreed to a new global malaria strategy for 2016-2030. The strategy aims to reduce the global disease burden by 40% by 2020 and by at least 90% by 2030.
STATISTICS
Nigeria is reported to have the enviable record of contributing about 25% of the world’s malaria burden, with approximately 51 million cases and 207,000 deaths reported annually while 97% of the total population is at risk of infection. In Nigeria, the disease is responsible for 60% of outpatient visits to health facilities, 30% of childhood deaths and 11% of maternal death. The financial loss due to Malaria annually is estimated to be 132 billion Naira in form of treatment costs, prevention and loss of man hours among other expenses, however it is a treatable and completely evitable disease.
THE JOURNEY SO FAR
In 2000, Nigeria joined other African nations, to initiate a more focused and calculated effort to reduce the burden of malaria. They agreed to set aside the 25th of April of every year to draw attention to the menace of Malaria and to drum up support for its elimination.
Consequently, the day was tagged “World Malaria Day”. The National Malaria Elimination Programme (NMEP) has implemented about three strategic plans. The first plan covered the period 2001-2005 and was developed after the African Summit on Roll Back Malaria to build partnership and garner political will. The second plan covered 2006-2010 and focused on vulnerable populations as the primary target groups for intervention that is, pregnant women, children less than five years and people living with HIV/AIDS. The third plan provided a road map for Malaria control in Nigeria. The current plan covers 2014-2020 and it aims to achieve pre-elimination and reduce Malaria related deaths to zero by 2020.
CHALLENGES
DRUG RESISTANCE AND TREATMENT FAILURE
Malaria drugs are meant to clear malaria parasites from the blood of an infected person and in the process diminish sources of infection in the community. Drug resistance, the ability of a parasite strain to survive and/or multiply despite the administration and absorption of drug given in doses equal to or higher than those usually recommended but within the tolerance of the subject, is a major challenge in the fight against malaria. Chloroquine used to be the drug of choice against malaria but chloroquine resistance which swept across endemic countries in the 1980s was the reason for treatment policy change that gave rise to the use of Artemisinin-based Combination Therapy (ACT) as the current drug of choice. ACT has played a major part in reducing the number of deaths due to Malaria over the past decade. However, Artemisinin-resistant Plasmodium falciparum has recently spread across large parts of Southeast Asia, and now threatens to destabilise Malaria control worldwide. Related to drug resistance is treatment failure. A failure to clear Malaria parasites or resolve clinical disease following drug treatment could be a function of non-patency and not necessarily drug resistance as not all cases of treatment failure is a function of drug resistance. Many factors can contribute to malaria treatment failure including incorrect dosing, non-compliance with the duration of dosing regimen, poor drug quality, drug interaction or misdiagnosis. The role of each of these in malaria treatment failures in Nigeria is not known and there is a need for a study in the effort to eliminate the disease.
INSECTICIDE RESISTANCE
Anopheles mosquitoes are vectors of malaria parasites.Control of Anopheles mosquitoes relies on the use of Long-Lasting Insecticide Nets (LLINs) and Indoor Residual Spraying (IRS). This method has been implemented successfully in many countries. However, success is being impeded by the development and spread of insecticide resistant malaria vectors in Africa, which may compromise the use of these vector control strategies. Only 4 classes of insecticide (carbamates, organophosphates, organochlorines and pyrethroids) are available for IRS, whereas the use of LLINs depends exclusively on pyrethroids. In Nigeria, Anopheline vector resistance to DDT andpyrethroids have been reported. The emergence of pyrethroid and DDT resistance in the major Afro-tropical malaria vectors would haveconsiderable implications for the success of vector intervention and the monitoring of ongoing control programmes. Hence, there is a strong need for the development of appropriate tools to monitor resistance in field populations of Anopheline mosquitoes in order to benefit from the contributions of the appropriate use ofchemical insecticides in Malaria elimination in Nigeria.
GLOBAL WARMING AND CLIMATE CHANGE
Available data suggest that the temperature of the world is increasing, with the last decade recorded as having the highest temperature. This increase in global temperature mainly as a result of human activity, is known as global warming. Global warming changes the climate, and climatic factors play important roles in the spatial and temporal distribution of malaria. The relationship between climatic variables and malaria transmission has been reported in many countries. Malaria has been identified as one of the most climate sensitive diseases,with studies suggesting significant associations between temperature and malaria incidence. Relative humidity and rainfall have also been associated with malaria transmission. Climate change expressed through changes in temperature and precipitation influences habitat suitability and can potentially shift the geographical range of Malaria. Warmer temperatures accelerate physiological processes of the mosquito vector, leading to increased activity such as biting rate, growth, development and reproduction. Extreme temperatures may also decrease survivorship of vectors, leading to a convex relationship between temperature and mosquito performance. In particular, temperature plays a key limiting role on malaria at the edge of the altitudinal distribution of the disease in highland regions, where the parasite is not likely to complete development during the lifetime of its vector. Drivers of malaria control and elimination need information to guide vector control challenges in an era of climate changes. Therefore, there is work to be done in this regard.
CONFLICTS, TERRORISM, INSURGENCY, INTERNALLY DISPLACED PERSONS AND MIGRATION.
Nigeria today is plagued by conflicts, terrorism, insurgency, migration and internally displaced persons. Virtually all regions ofthe country are affected with the northeast bearing the highest burden. The massive movement of non-immune people across areas infested with the malaria vector is one of the consequences of civil unrest. The malaria control situation is threatened by the impact of refugees, returnees, internally displaced populations, and natural disasters, i.e. flooding, that put added strain on an already weakened system from years of conflict and that may destabilize whatever gains that have been made. The situation is aggravated by an increase in population due to refugees, returnees and internally displaced persons. Accordingly, the country experiences exceedingly high malaria transmission intensities with inherent high morbidity and mortality rates. Every effort is needed to understand the dynamics of this issue in the effort to control and eliminate malaria.
POLITICAL WILL, LEADERSHIP AND FUNDING
An important action for mobilizing and encouraging governments to continue to support malaria programmes is to generate political will. Since 2000, there has been an increasing political drive to eliminate malaria. The transition from sustained control, once achieved, to elimination demands a shift in focus. It requires significant national commitment, and sustained investment and financial support. To maintain a malaria-free status, a country must show that it has the necessary political will and vision, has created the required legislative and regulatory framework and has adequate financial and administrative resources, personnel and technological capacity.Effective and sustained control is an important prerequisite for elimination. The most important challenge in battle against malaria in Nigeria is the lack of political will. Until this is overcome, achieving elimination may be a mirage. When there is the desired political will, effective leadership will emerge to coordinate elimination efforts. Political leaders should muster the political will to create an enabling environment within which strategies to support elimination would operate: appropriate research, a well-functioning health system, community participation, sustainable financing, a national and regional legal framework, and political stability are all crucial.A certain level of financial support is also required to achieve elimination, prevent resurgence and support larger goals of regional elimination and global eradication.
SUCCESSES
Nigeria has recorded a 35% decline in malaria cases in five years with only 25% of children under the age of 5 testing positive for the disease in 2015 compared to 40% in 2010. The result of the 2015 Nigeria Malaria Indicator Survey (NMIS) released by the National Malaria Elimination Programme (NMEP), National Populations Commission and National Bureau of statistics show a marked decrease in prevalence of the disease among children under five, and major improvements in prevention and treatment. The decrease corresponds with expanded malaria prevention interventions. There has been considerable progress in the control of malaria over the years. A 61% increase in the ownership of insecticide treated nets among households was observed from 2008-2015. The percentage of children who slept under a mosquito net increased from 2008-2015by 38%
In 2010, only 12% of children took ACT. However, over five years, this percentage increased to 38%.
There has also been reasonable progress in the percentage of pregnant women who sleep under an insecticide treated net, with a 44% increase in percentage from 2008-2015. Furthermore, there was a 32% increase in the percentage of pregnant women who took anti-malarial medication during their first pregnancy from 2008-2015.
THE WAY FORWARD
The past decade has seen considerable progress in reducing preventable mortality in low- and
Middle-income countries (LMICs), as evidenced by the 50% reduction in childhood deaths,
25% reduction in malaria cases, and the World Health Organization (WHO) certification of
four countries as malaria-free. Nigeria can be one of the malaria free countries as well.The Lancet Commission on Investing for Health determined that if the right investments are made in scaling up existing health interventions and in developing new prevention, treatment, and surveillance tools, the world could achieve a “grand convergence” by 2035, with preventable deaths reaching universally low levels and economic benefits exceeding cost by a factor of 9–20. Historically, LMICs that have aggressively adopted new tools have seen an additional 2%-per-year decline in child mortality rates compared with non-adopters. However, adoption alone of new and existing tools with poor implementation will have little impact on disease transmission in the long term. Malaria control and elimination demand new tools and technologies as well as better mechanisms for maintaining detailed surveillance and spatial decision support systems (SDSS) that improve reporting and timeliness of activities. The majority of new products currently under development are in partnership with Product Development Partnerships (PDPs) such as the Program for Appropriate Technology in Health (PATH); Malaria Vaccine Initiative (MVI), Medicines for Malaria Venture (MMV), the Innovative Vector Control Consortium (IVCC), the Foundation for Innovative New Diagnostics (FIND), Novartis Institute for Tropical Diseases (NITD), Drugs for Neglected Diseases Initiatives (DNDi), and the European Vaccines Initiative (EVI). There are over 100 products in the research and development pipeline that will benefit regional elimination and global eradication goals. These range from innovative diagnostics, medicines, vaccines, and vector control products to improved mechanisms for surveillance and targeted responses.
Seasonal Malaria Chemoprevention (SMC)
SMC involves administration of treatment on a monthly basis to coincide with the annual peak in malaria transmission. This intervention is highly effective in reducing the incidence of clinical malaria and anemia in young children, and, in 2012, WHO recommended implementation of SMC for children under the age of five in areas of the Sahel sub region of Africa with highly seasonal transmission. This recommendation is now being implemented increasingly in countries of the Sahel. Although less extensively researched, and not yet recommended by WHO, evidence suggests that SMC is as effective in older children.
Vaccines
Vaccines are generally classified into three approaches: Pre-erythrocytic vaccines aim to prevent blood-stage infection; blood-stage vaccines aim to clear parasitaemia and prevent clinical disease; and transmission-blocking vaccines aim to prevent infection of mosquitoes and interrupt malaria transmission in populations. There is a growing appreciation that vaccines combining multiple targets and stages will be required for achieving and sustaining elimination.
The development of effective malaria vaccines has been a major goal of the malaria research community for many decades. In 2006, the global Malaria Vaccine Technology Roadmap established the goal of developing an 80%-effective vaccine against P. falciparum malaria by 2025 that would provide protection for longer than four years, with an interim landmark of a 50%-effective vaccine of one-year duration by 2015. The new Technology Roadmap updated in 2012 outlines that by 2030, vaccines should be developed that provide at least 75% protective efficacy against clinical malaria, reduce transmission of the parasite, and can be deployed in mass campaigns. Because of the complex life cycle of the Plasmodium parasite, host immune response efforts have been focused most recently on the pre-erythrocytic stage of infection to protect against the early stage of malaria infection and thereby block disease progression to red blood cells and clinical malaria. RTS,S, a pre-erythrocytic vaccine for the prevention of clinical P. falciparum malaria in children, is the first vaccine to successfully complete a Phase III clinical trial. The vaccine has recently been approved by the European Medicines Agency, and WHO was imminently expected to make the first malaria vaccine policy recommendations. The trials, conducted in African children, demonstrated a vaccine efficacy for clinical malaria of 50% in children aged 5–17 months old but only 30% in infants, the target population. While RTS,S demonstrates that a malaria vaccine is possible, an ideal candidate to support global eradication efforts would need to have a higher efficacy .
Paraguay was recently declared malaria free by WHO. From 1950 to 2011, Paraguay systematically developed policies to control and eliminate malaria. A five year plan to consolidate the gains, prevent re-establishment of transmission and prepare for elimination certification was launched in 2011. Activities focused on robust case management, engagement with communities, and education to make people aware of ways to prevent malaria transmission. Dr Risintha Premaratne of Sri Lanka also said “Sri Lanka became a malaria free country by eliminating the Parasite and not the vector” He also said the principle strategy used as keys to Sri Lanka’s success are vector control, access, surveillance and treatment.
CONCLUSION
Like every other issue plaguing Nigeria, it is not impossible to completely eliminate Malaria by 2030. However, lack of political will, poor leadership, corruption, poor sanitation practices in Nigeria using Irefin as a case study and many other challenges to malaria elimination, it is safe to say that except drastic measures are put in place to tackle these challenges, malaria elimination by 2030 remains a mirage.
REFERENCES
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- Chukwuocha UM (2012) Malaria control in Nigeria. Primary Health Care2:118.doi: 10.4172/2167-1079.1000118
- Dawaki, S, Al-mekhalfi Ibrahim, Atroosh, Abdulsalam (2016) Is Nigeria winning the battle against malaria?. Prevalence, riskfactors and KAP assessment among hausa communities in Kano state. Malaria journal, 15,351
- Health think team, malaria status in Nigeria. Available at https://Healththink.org/malaria-in-nigeria-where are we now/ Accessed 14th July 2018
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- The Guardian News – Nigeria records 35% decline in malaria cases. Available at https://guardian.ng/news/nigeria-records-35-per-cent-decline-in-malaria-cases/ Accessed 14th July 2018
FRANCES CHUKWU
4th year medical student,
University of Ibadan,
Nigeria.
