Nigeria: Malaria May Never Be Eliminated in Nigeria As Efforts Suffer Setbacks

Mosquito.

The global drive to eliminate malaria by 2030 is gaining momentum. The optimism is derived from the fact that several diseases have successfully been eradicated and eliminated such as smallpox and yaw.

Experts on the occasion of the World Malaria Day (WMD), April 25, have come up with another slogan, "Zero malaria starts with me," a grassroots campaign that aims to keep malaria high on the political agenda, mobilise additional resources, and empower communities to take ownership of malaria prevention and care.

Unfortunately, more reasons have emerged why malaria may never be eliminated from Nigeria and perhaps worldwide.

According to the World Health Organisation's (WHO) 2018 World Malaria Report, after more than a decade of steady advances in fighting malaria, progress has levelled off and no significant gains were made in reducing malaria cases in the period 2015 to 2017. The estimated number of malaria deaths in 2017, at 435,000, remained virtually unchanged over the previous year.

Why?

Funding gap, sectarian crisis, misuse smear marginal progress

In Nigeria, funding gap is threatening the marginal progress made in reducing malaria cases and deaths.

National coordinator, National Malaria Elimination Programme (NMEP), Dr. Audu Bala Mohammed, in an exclusive interview with The Guardian said there appears to be some increase in the reported number of cases since 2015.

The NMEP boss said the recent increase in cases, though not mortality, are attributable to significant shortfalls in funding requirement. He said about $1.12billion (N403.2 trillion) is needed, for the period 2018 - 2020, for the procurement of the malaria intervention commodities.

Mohammed, however, said the government and development partners could only meet about 50 per cent of this need and so in the last 18 months thereabout, malaria intervention has not been on any significant scale in 13 states of the country.

Mohammed said they already anticipate the implication of that in the next round of reporting and government has approached some banks - World Bank, Africa Development Gap, and Islamic Development Bank (IsDB) to raise some financial instruments to address the gaps in these states and hopefully, the activities will commence again in the third quarter (Q3) of the year.

Mohammed said there are also challenges of places that are difficult to reach either because of sectarian crisis or difficult terrain that makes access challenging. He said there are also issues with misuse, non-use or abuse of some of the intervention commodities. "We have instances of the nets being used for a variety of non-malaria related activities such as farming, there is the inadequate practice of testing before treatment and inadequate capture of data especially of activities from the private health sector," Mohammed added.

Fake drugs top reasons malaria still kills so many

Some studies have blamed the slow progress in efforts to eliminate malaria to rise in fake anti-malarials.

According to a report published by The Conversation, research on the pharmaceutical industry has revealed that one reason for malaria's continued virulence in the developing world is ineffective medicine. In fact, in some poor African countries, many malaria drugs are actually expired, substandard or fake.

According to recent WHO estimates, globally, some 200,000 preventable deaths occur each year due to anti-malarial drugs that do not work. Substandard and counterfeit medicines may be responsible for up to 116,000 malaria deaths annually in sub-Saharan Africa alone.

A 2014 article in the Malaria Journal showed fraudulent pharmaceuticals are on the rise and reports of counterfeit or falsified anti-malarials rose 90 percent between 2005 and 2010.

How true is this and what is the situation and efforts to curb the menace in Nigeria? The NMEP boss said evidence from surveys by researchers and the National Agency for Food and Drug Administration and Control (NAFDAC) has not demonstrated that the country has such a large-scale challenge of fake drugs when it comes to the Artemisinin-based Combination Therapies (ACTs).

Mohammed added: "We will continue on our pharmacovigilance. There is a general context of combating fake drugs in the country. But my point here is that we do not have a situation on our hands where we need to attribute any increase in malaria burden to fake drugs. We need to continue to be vigilant but we also need to do the right things when it comes to malaria. Let us get tested and be sure it is malaria we are treating instead of blaming non-response on fake malaria."

Meanwhile, in 2012, a research team from the U.S. National Institutes of Health found that about one-third of anti-malarial medicines distributed in Southeast Asia and sub-Saharan Africa were of poor quality. A few years prior, fully 44 percent of anti-malarial supplies in Senegal had failed quality control tests.

For as long as effective medicines have existed, people have produced fake versions. That is because counterfeiting pharmaceutical drugs is profitable business for manufacturers. This illegal activity is most common in places with little government oversight and limited access to safe, affordable and high-quality medicines.

Various reports have found that many fake medicines originate in India, followed by China, Hong Kong and Turkey. Some illicit drug manufacturers appear to have connections with organised crime groups.

Poor sanitation and waste disposal fuel proliferation of mosquitoes

Refuse dumps and stagnant water bodies are common sites in most Nigerian cities and even villages.

Unfortunately, several researches have shown that poor sanitation and waste disposal fuels the proliferation of the malaria vector, mosquito.

According to the WHO, mosquitoes transmit the world's most important parasitic infectious disease, which breed in fresh or occasionally brackish water.

A study published in the Nigerian Journal of Medicine concluded that regular cleaning of house surroundings was associated with reduced prevalence of malaria infection in rural areas in Nigeria.

Another study published in African Journal of Health Sciences found inhabitants of houses surrounded by bushes or garbage heaps and swamps or stagnant water showed higher malaria parasite prevalence and densities compared with those from cleaner surroundings.

"Our data indicates that poor environmental sanitation and housing conditions may be significant risk factors for malaria parasite burden... "

President, Pharmaceutical Society of Nigeria (PSN), Mazi Sam Ohuabunwa, urged Nigerians to clean their environment, especially by draining stagnant water to put malaria, a disease caused by anopheles mosquitoes, at bay.

Ohuabunwa said malaria thrives in dirty environment, thus cleaning the surroundings is non-negotiable to rid the country of the disease.

He said: "The PSN calls on the community to take action by cleaning your environment, get rid of stagnant water and pools; cover up gutters in residential areas and ensure your garden is not over grown. Interrupting at least three mosquito life cycles can potentially stop the transmission of malaria parasite by mosquito."

The PSN President, however, said a concerted effort is required to achieve this and therefore called on Local Development Authorities to coordinate and implement an environmental policy to achieve this.

Growing drug and insecticides resistance

The largest ever-genetic study of mosquitoes revealed the movement of insecticide resistance between different regions of Africa and finds several rapidly evolving insecticide resistance genes.

According to the study published 2017 in the journal Nature, mosquitoes transmit malaria and rising resistance to insecticides is hampering efforts to control the disease.

Earlier genetic analysis of mosquito populations in Africa showed that recent successes in controlling malaria through treated bed-nets has led to widespread insecticide resistance in mosquitoes.

Also scientists at the Nigeria Institute of Medical Research (NIMR), Yaba, Lagos, had in June 2017 revealed that mosquitoes in 18 states in Nigeria have developed resistance to the Long Lasting Insecticide treated Nets (LLIN) insecticide nets, with Lagos, Ogun and Niger state having the highest incidence of cases.

Other states where the resistance were also detected include Jigawa, Katsina, Kebbi, Sokoto, Zamfara, Benue, Kwara, Nasarawa, Plateau, Anambra, Enugu, Rivers, Ondo, Osun and Oyo state, with the outcome of the study identified as a major threat to the eradication of malaria in Nigeria by 2030.

Also, scientists had in 2017 alerted to the rapid spread of 'super malaria' in South East Asia, which they said posed a global threat to efforts to eliminate the mosquito-borne disease.

They feared that this dangerous form of the malaria parasite has become untreatable with the WHO recommended drug-of-choice, ACT.

The researchers from the Mahidol-Oxford Tropical Medicine Research Unit in Bangkok in their study published in The Lancet Infectious warned that the menace is spreading. It emerged in Cambodia but has since spread through parts of Thailand, Laos and has arrived in southern Vietnam.

The fear is palpable in Nigeria and indeed Africa where resistance to the drugs would be catastrophic, since 92 per cent of all malaria cases happen in the continent.

What is the current situation in the country as regard resistance of the malaria parasite to the drug of choice and the growing resistance of the malaria vector, mosquito, to insecticide-treated bed nets?

Mohammed, however, said without equivocation that malaria remains sensitive to the nationally recommended ACTs. He said the drug efficacy studies continue to demonstrate sustained sensitivity of 95 per cent and above to the drugs.

The NMEP boss said the major challenge is the need to optimise testing before treatment and need to emphasize that not all fevers are due to malaria. He said they are aware of various anecdotal claims of resistance to the ACTs but each rigorously conducted study proves to the contrary in Nigeria.

Mohammed said they are also aware of the challenge of resistance in South East Asia and are collaborating with partners to monitor resistance in Nigeria. "So, for now, we do not have resistance to ACTs but we encourage testing to be sure that malaria is the cause of a given fever episode," he said.

Mohammed, however, the NMEP have evidence of insecticide resistance in some parts of the country and are currently conducting entomological surveillance so as to update the map. He said, for the places where resistance to the insecticide has been reported, they are making efforts to deploy a different type of LLIN.

What is NMEP doing about growing insecticide? Mohammed said: "We remain focused on monitoring and responding appropriately to resistance issues as they emerge. For now, we are fine with the drugs. For the nets we are assessing where the resistance level warrants a change in the type of net to be deployed and we are acting accordingly with our partners."

Nigeria carries more than 25% per cent of global burden

Despite efforts by the governments at all levels and the international community, malaria still kills no fewer than 81,640 Nigerians and infects 53.7 million yearly.

The country also loses N450 billion yearly in intervention and treatment costs due to malaria.

Mohammed said: Currently, it is estimated that about 53.7million cases of malaria occur in Nigeria. Nigeria has 25 per cent of global burden and 53 per cent of cases in West Africa annually and with about 81,640 deaths that is 19 per cent of global burden and 45 per cent of deaths in West Africa."

How much does Nigeria lose to malaria yearly? Mohammed said: "It is difficult to estimate. Some scholars had estimated this to be N132 billion annually. But that was an old study and the commodities we use for malaria control has changed since that publication.

"In 2013 another study indicated that at the household level, direct expenditure is between N4000 to N7000 for malaria. With about 40 million households this figure will be translating to N160 - N280 billion directly lost to malaria. As indicated above the need by the country is close to N450 billion. If Nigeria was to be free of malaria, close to half a trillion could be saved in intervention costs."

Mohammed, however, said from 2010 -2018 there has been a steady decline in malaria-related deaths from 145,000 to the current figure to current figures of greater than 81,640. Regarding cases, he said, there was a decline up to 2015 but since then there appears to some increase in the reported number of cases.

What are the economic implications of malaria to Nigeria? Mohammed said malaria affects the country economically in terms of cost of its prevention and treatment, demonstrable reduction in productivity of the farming population, significant loss of work days for victims of malaria and their relatives who have to look after them, and overall impairment on the development.

Lack of tested, effective, cheap and available vaccine

Despite Nigeria having the greatest burden of malaria in Africa and indeed the world, Malawi last week became the first of three African countries to launch of the world's first malaria vaccine in a landmark pilot programme.

According to the WHO, Malawi is the first of three in Africa in which the vaccine, known as RTS,S, will be made available to children up to two years of age; Ghana and Kenya will introduce the vaccine in the coming weeks.

Malaria, according to the WHO, remains one of the world's leading killers, claiming the life of one child every two minutes.

Why was Nigeria not chosen? The WHO explained: "Following a request by WHO for expressions of interest, the pilot countries were selected from among ten African countries. Key criteria for selection included well-functioning malaria and immunization programmes, and areas with moderate to high malaria transmission."

What informed the pilot studies? Proven results: Thirty years in the making, RTS,S is the first, and to date the only, vaccine that has demonstrated it can significantly reduce malaria in children.

Can malaria truly be eliminated considering the complications and how?

Globally, the elimination net is widening, with more countries moving towards zero indigenous cases: in 2017, 46 countries reported fewer than 10 000 such cases, up from 44 countries in 2016 and 37 countries in 2010.

The number of countries with less than 100 indigenous cases - a strong indicator that elimination is within reach - increased from 15 countries in 2010 to 24 countries in 2016 and 26 countries in 2017.

WHO certified Paraguay as malaria free in 2018, while Algeria, Argentina and Uzbekistan have made formal requests to WHO for certification. In 2017, China and El Salvador reported zero indigenous cases.

One of the key Global Technical Strategies for malaria 2016-2030 (GTS) milestones for 2020 is elimination of malaria in at least 10 countries that were malaria endemic in 2015. At the current rate of progress, it is likely that this milestone will be reached.

In 2016, WHO identified 21 countries with the potential to eliminate malaria by the year 2020. WHO is working with the governments in these countries known as "E-2020 countries" to support their elimination acceleration goals.

Although 11 E-2020 countries remain on track to achieve their elimination goals, 10 have reported increases in indigenous malaria cases in 2017 compared with 2016.

The World Health Assembly adopted the GTS in May 2015. It provides a comprehensive framework to guide countries in their efforts to accelerate progress towards malaria elimination. The strategy sets the target of reducing global malaria incidence and mortality rates by at least 90 per cent by 2030.

However, the WHO said urgent action is needed to get the global response to malaria back on track - and ownership of the challenge lies in the hands of countries most affected by malaria.

Founder/Chairman, Safe Medicines Foundation and Immediate Past President of PSN, Ahmed I. Yakasai, that he sincerely believe that if Uzbekistan, Iraq, Argentina, Costa Rica, Oman, Turkey, Georgia, Syria and Sri Lanka can eliminate Malaria, then Nigeria can. But, the pharmacist said, for Nigeria to eliminate malaria it cannot be business as usual, that it will require committed and concerted efforts by all stakeholders.

Yakasai said government must increase funding to malaria elimination programmes and decisions on strategies to adopt including surveillance must be evidence-based.

"Timely detection and reporting of malaria incidence must be systemized, high risk area must be adequately spared. Education on hygiene, malaria prevention, and use of Long Lasting Insecticides Nets must be strengthened. This information must reach the people in rural communities not just urban centres. It must cascade to the grassroots," he added.

Yakasai said Nigeria is currently the world capital of malaria but honestly that should not be the case. He said Nigeria could eliminate malaria in the next two decades if only we look inward not outward. "Harness all our human and capital resources and declare a war against malaria in the best interest of our citizens and nation," Yakasai said.

Mohammed said: "Malaria can be eliminated from any geographical entity and ultimately eradicated globally. However, to achieve this, it requires the concerted effort of all. It is not only government-based actions. Individuals, organisations, politicians, private sector, researchers, media, teachers, religious leaders, etc. all have their roles. The approach consists of disease prevention, correct diagnosis, effective treatment, active surveillance, and effective use of data. There is a need for stronger political will and well-coordinated engagement of relevant sectors."

He said the WMD celebration is not primarily to celebrate successes but Nigeria has made progress. "Malaria deaths continue to drop, we are getting back on track with net distribution, Most places have ACTs, there is some increase in domestic resources, malaria will benefit from the Basic Health Care Provision Fund and primary health care is being strengthened.

However the major goal of the WMD is to sensitise the world, the nation and all stakeholders about the unfinished business of malaria elimination.

Hence the theme for this year's celebration is "Zero Malaria Starts With Me" and to this we are saying Join Me," Mohammed said.

WHO's Strategy for Malaria Control, which forms the basis of the Roll Back Malaria initiative, identifies four main interventions:

*Reducing mortality, particularly among children, by early case-detection and prompt treatment with effective anti-malarial drugs

*Promoting the use of insecticide-treated bed nets, especially by children and pregnant women

*Prevention of malaria in pregnancy by applying intermittent preventive therapy

*Ensuring early detection and control of malaria epidemics, especially in emergency situations.

Where appropriate, the WHO said, countries and communities are being encouraged to reduce mosquito-breeding sites by filling in and draining water bodies and through other environmental management schemes.

Ohuabunwa added: "We also call on other health professionals to ensure quick and effective response to save lives especially in at risk populations, children under five and pregnant women. To end malaria for good, while communities are taking actions to control the vector, we must do our part by providing effective treatment. A combination of disruption of breeding and elimination of parasite from the system has been proven to lead to zero malaria.

"Finally we call on the policy makers including the Federal Ministry of Health to strengthen National Malaria Surveillance by incorporating reports from pharmacists operating in community settings. Evidence currently shows that most patients visit their community pharmacist first when they suspect malaria. Therefore health data reports from community pharmacists will improve data quality and resulting intervention. Today we start a zero malaria community and it start with me."

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