Following an 8-year conflict in north-eastern Nigeria, two-thirds of health facilities have been completely or partially destroyed leaving some 3.7 million internally displaced persons (IDPs) at risk of life-threatening diseases. In Borno State, the number of malaria cases and deaths has soared, particularly among young children. WHO recently launched a special campaign aimed at rapidly reducing the malaria burden among children under 5 years of age. Dr Pedro Alonso, Director of the WHO Global Malaria Programme, explains.
When did WHO first learn that malaria was the number one killer in Borno State?
Sometimes a major disease like malaria can fall into a blind spot in the context of a humanitarian crisis. That was the case during the Ebola epidemic where, in many affected countries, malaria killed far more people than Ebola itself. During the 2016 yellow fever outbreaks in Angola and the Democratic Republic of the Congo, malaria was again the primary cause of death.
Fast forward to the crisis in Nigeria which has left millions of IDPs across Borno State with limited access to basic health care. By the end of last year, state health authorities were reporting that about 50% of all deaths were due to malaria. These reports were confirmed in early 2017 by a WHO emergency surveillance system.
How did WHO respond?
Based on confirmed data and on-the-ground intelligence, we took swift action. In collaboration with the Borno State Ministry of Health, WHO developed a framework that aims to dramatically reduce malaria mortality in the region, particularly among children under 5.
Recommended actions include: preventing malaria through the use of bed nets and by spraying insecticides on the inside walls of shelters; treating malaria by expanding access to health facilities for at-risk populations; and improving data collection through strengthened surveillance systems. WHO is working closely with the Borno State Ministry of Health and partners to make progress on all of these fronts.
As part of the initial response, the framework also recommends the use of monthly rounds of age-targeted mass drug administration (MDA), a WHO-recommended approach for rapidly reducing malaria mortality and morbidity in complex emergency settings. Through MDA, all individuals in a targeted population are given antimalarial medicines (often at repeated intervals) regardless of whether or not they show symptoms of the disease.
Beginning in July 2017, WHO teamed with local health authorities on the launch of a special, time-limited MDA campaign aimed at saving lives of under-5 children in high transmission areas of Borno State. Through the campaign, which runs until November, children in 5 targeted areas are receiving monthly rounds of antimalarial medicines.
This emergency MDA campaign is similar to another programmatic approach recommended by WHO in Africa’s Sahel subregion known as seasonal malaria chemoprevention (SMC). In the context of the Borno State humanitarian response, the terms MDA and SMC are being used interchangeably.
What, if anything, is unique about this campaign?
While chemoprevention is a known malaria control intervention in many parts of the Sahel, this is first time it has been implemented in Borno State. The current campaign also marks the first time that antimalarial medicines have been delivered on a mass scale alongside the polio vaccine in an emergency humanitarian setting.
WHO teams in Borno State are leveraging the existing infrastructure and machinery of the polio campaign to reach children at high risk of malaria, including in very remote areas. This integrated campaign with WHO’s polio and health emergency teams is an example of unprecedented collaboration to tackle the leading cause of death in a displaced population.
How many children are being reached through the campaign?
The campaign was launched in July, at the onset of the rainy season. By the end of the second monthly round, WHO and partners had delivered both antimalarial medicines and the polio vaccine to about 1.2 million children in 5 Local Government Areas (LGAs) areas of Borno State (about 60% of the total under-5 population). A third campaign cycle kicked off on in mid-October and is expected to again reach all children under five in the targeted areas. A fourth and final monthly round is planned in mid-November.
Is the campaign delivering results?
We are very encouraged by the preliminary results from this campaign shared by WHO colleagues in Nigeria. We expect to report significant declines in both malaria case incidence and mortality in the intervention areas in the coming weeks. But we will not know the full impact of the campaign until December.
Are some areas of Borno State still inaccessible?
Over the last year, many areas have become accessible with a reasonable level of security. WHO’s polio teams have developed the capacity and infrastructure to roll out massive immunization campaigns across this state, even among hard-to-reach populations. Several areas, however, are still off limits due to the security threat posed by Boko Haram.
How can community health workers ensure that children receive the full course of antimalarial medicines?
Each monthly cycle of seasonal malaria chemoprevention includes a 3-day treatment course. During this particular campaign, the community health worker provides the first dose of treatment in the child’s home (known as “directly observed treatment”). Parents or caregivers are given the task of administering the remaining 2 days of treatment. Treatment adherence will be monitored closely after the third and fourth cycles of this campaign.
How will the State Ministry of Health and partners ensure that children continue to be protected from malaria after the emergency campaign has ended?
WHO has strongly recommended to state health authorities and partners that the campaign be followed up with adequate vector control – either insecticide-treated nets or indoor residual spraying, depending on the setting. We have appealed to donors to help the State Ministry of Health fund and implement these prevention measures.
Is this a one-time campaign or will it be rolled out again during next year’s rainy season?
This large-scale campaign is intended as a stop-gap measure to protect young children from malaria in an emergency humanitarian setting. In parallel, WHO and partners are working to address the conditions that have led to an accelerated rate of child mortality in Borno State – particularly the deadly combination of severe acute malnutrition and lack of access to malaria prevention and control. By next year, we expect these conditions to be much improved. A decision on whether to carry out another chemoprevention campaign in 2018 will depend largely on a malaria landscape analysis and the security situation in Borno State.
Could this strategy be deployed in other countries or areas?
We hope that lessons learned from the campaign in north-eastern Nigeria can be applied in other emergency settings. We are currently exploring, for example, whether a similar model could be deployed in South Sudan where - again - WHO estimates show that malaria is the primary cause of death in a displaced population following a protracted conflict. As in Borno State, we are seeing a confluence of factors in parts of South Sudan that have led to an acceleration in the rate malaria deaths among young children: ongoing high transmission of malaria, inadequate access to malaria prevention and control services, and severe malnutrition.