Niger

Malaria facts

Photo: Young girl from Niger

Niger is one of the poorest countries in the world, with 80 percent of the population living on less than US $2 a day and with only 48 percent of the population having access to health centers within a radius of 0-5 km. The life expectancy at birth is 60.4 years. Although 84 percent of the population lives in rural areas, only 24 percent of all health care providers are found in rural areas.[1] 

Malaria is endemic throughout Niger and, as one of 11 countries that bear 70% of the global malaria burden, the country is considered under the “High Burden to High Impact” (HBHI) approach. In 2020, Niger accounted for 3.3% of global malaria cases 2.8% of global deaths due to malaria, and 6.7% of malaria cases in West Africa. [2] 

However, the estimated number of cases decreased by 11%, between 2017 and 2020 (from 364 per 1000 population to 324 per 1000 of the population at risk) and the number of deaths decreased by 14% in the same period (from 0.84 per 1000 population to 0.72 per 1000 of the population at risk).[2] The decrease in death rate reflects improvements in the quality of hospital treatment of severe malaria cases, linked to the capacity building of health care facilities in the treatment of malaria cases – training health workers in the treatment of malaria cases, the availability of diagnostic resources and drugs for the management of malaria.[6]  

There is limited new data available on coverage with insecticide-treated nets (ITNs). The 2012 Demographic and Health Survey (DHS) found that 61% of households reported having at least one ITN.[1] 

As well as malaria, acute malnutrition is a major public health problem in Niger. According to the SMART nutrition survey 2019, the rate of chronic malnutrition in children under 5 years of age is 45.7%, and global acute malnutrition affects 10.7% of children, 2.7% of whom are severely malnourished. Acute malnutrition peaks each year between June and October, corresponding with the lean season and the peak malaria period – 4 months during the rainy season when the majority of malaria cases (60 percent of cases) occur. To prevent these malaria peaks, Niger has been undertaking seasonal malaria chemoprevention (SMC) since 2013 and in 2016 combined SMC with acute malnutrition screening.[6] 

Impact of COVID-19 

The COVID-19 epidemic has affected Niger since March 2020. It has had a negative impact on the delivery of program activities, including: 

  • The Malaria Indicator Survey (MIS) has been postponed  
  • Capacity building for health care providers has been delayed.  
  • Some health workers were infected, which led to the closure of certain health care facilities and required certain preventive services to be stopped, including antenatal consultations and vaccinations.  
  • The implementation of the long-lasting insecticidal net (LLIN) and seasonal malaria chemoprevention (SMC) campaign had to be postponed and adapted. 
  • Protective equipment for health workers had to be improved to protect them and give patients confidence, in order to guarantee the continuity of services.  

An integrated contingency plan has been developed for the malaria control program with technical support from WHO.[6] 

Severe malaria case management 

Niger’s Malaria Diagnostic and Treatment Guidelines, updated in December 2017, state that severe cases should be treated with injectable artesunate as first-line therapy. In facilities where full treatment of severe malaria is not possible, but injectable forms are available, it is recommended that children and adults be given a single intramuscular dose of artesunate (or artemether) and then referred for appropriate care. [6] 

Severe malaria case management

The National Malaria Control Programme’s (NMCP’s) case management objectives as outlined in the NMSP1 are:

  • At least 90 percent of suspected cases of malaria have undergone a test (RDT or microscopy)
  • At least 90 percent of confirmed malaria cases in health facilities have received adequate antimalarial treatment in accordance with national guidelines
  • At least 90 percent of confirmed severe malaria cases in health facilities have received adequate antimalarial treatment in accordance with national guidelines
  • At least 90 percent of simple malaria cases confirmed by community relays have received correct antimalarial treatment in accordance with national guidelines.

In facilities where injectable artesunate is not available, it is recommended that children under 6 years of age be treated with a single rectal dose of artesunate (10 mg/kg) and referred immediately.[6] 

There is limited information available about provider behavior. According to the Service Availability and Readiness Assessment (SARA) survey, 2019), 64 percent of malaria cases were treated appropriately, and 86 percent of confirmed cases were treated according to the national directives.[1] 

Malaria in pregnancy 

Niger’s Malaria Diagnostic and Treatment Guidelines state that intermittent preventive treatment for pregnant women (IPTp) dosing should begin in the fourth month of pregnancy (after quickening) until delivery, with an interval of one month between doses. Sulfadoxine-pyrimethamine (SP) is to be administered as directly observed treatment by qualified health personnel.[1] 

All uncomplicated malaria cases during the first trimester should receive oral quinine in three daily doses for seven days, as ACTs are contraindicated during this period. During the second and third trimesters, all uncomplicated cases are to be treated orally with ACTs (or with oral quinine for seven days if there are no ACTs available). For severe malaria, pregnant women should receive injectable artesunate or injectable quinine if artesunate is unavailable or not tolerated.[1] 

However, pregnant women customarily wait until their last month of pregnancy before seeking care. A survey conducted in 2019 (Service Availability and Readiness Assessment, SARA) showed that while 80% of facilities offer IPTp services, only 47% have health providers trained in IPTp.[1] Other than the fee for the health card (200 FCFA or Euro. 40 cents), all ANC and IPTp services are free of charge. 

The percentage of women receiving IPTp increased between 2017 and 2020; however, there is a decrease in the proportion of women getting subsequent doses after the first (National Malaria Control Programme (NMCP) quarterly reports). In this time period, IPTp1 increased from 66% to 71%, IPTp2 from 42% to 64%, and IPTp3 from 31% to 46%.[1] 

Seasonal malaria chemoprevention (SMC) 

Niger initiated SMC with sulfadoxine-pyrimethamine plus amodiaquine  (SPAQ) in the southern part of the country in 2013, targeting 205,959 children between 3 months and 5 years of age during the SMC campaign. The refusal rate for SMC campaigns is very low and decreases with each round: for 2020, ~4.5 million children were treated during the four rounds and no children/caregivers refused treatment.[1] 

With the new risk mapping developed in 2020, the number of districts eligible for SMC increased from 61 in 2020 to 67 in 2021.[1] The extension of SMC to these six new districts will enable 164,771 additional children to be treated compared with 2020.[6]  

The treatment is delivered through door-to-door campaigns as well as fixed distribution sites. Starting in 2016, malnutrition screening was added to the SMC campaign. Children identified as being severely or moderately malnourished are referred to a Centre de santé integré/Integrated health center (CSI) with a nutrition treatment center.[1] 

The implementation of SMC in Niger is synchronized with Burkina Faso and Mali and cross-border activities are organized between these three countries in general, and planning, supervision and evaluation activities in particular. These cross-border activities help to improve coverage in insecure areas by reaching populations at the borders.[6] 

Diagnosis and treatment

Niger’s Malaria Diagnostic and Treatment Guidelines, updated in December 2017, state that any suspected case of malaria must be confirmed by a diagnostic test – either a rapid diagnostic test (RDT) or microscopy – followed by treatment with an artemisinin-based combination therapy (ACT).[1] 

Microscopy is performed in district hospitals and in the private sector, while RDTs are used in health centers and at the community level. In 2019, 91 percent of the health facilities offered rapid diagnostic tests (88 percent in 2015) and 24 percent microscopy (20 percent in 2015). Sixty one percent of the facilities have a health worker trained in malaria diagnostics and treatment (52 percent in 2015).[1] 

There is limited information available about provider behavior. According to the Service Availability and Readiness Assessment (SARA) survey, 2019), 64 percent of malaria cases were treated appropriately, and 86 percent of confirmed cases were treated according to the national directives.[1] 

Community case management

In an effort to increase access to care for children under five years of age, the Niger Ministry of Health (MoH) promotes community health activities through nationwide expansion of integrated community case management (iCCM) by community health workers (CHWs) known as relais communautaires in villages further than five kilometers from a health facility. In July 2016, a new community health policy that details its implementation and management was adopted.[1]  

The iCCM program includes the diagnosis with rapid diagnostic tests (RDTs) and treatment with artemisinin-based combination therapies (ACTs) for malaria as well as diagnosis and treatment of pneumonia and diarrhea, and malnutrition screening in addition to referral for all illnesses. [1] 

CHWs participate in a 10-day training using national guidelines adopted from UNICEF training materials and receive a kit containing the necessary supplies (including ACTs and RDTs) provided in the Tahoua and Dosso regions by PMI and UNICEF. The MOH has determined that CHWs should receive an incentive of 10,000 CFA  a month, of which half should be provided by donors. [1] 

An estimated 16,000 CHWs are needed to assure national iCCM coverage.[1] At present the density of CHWs per 10,000 inhabitants is higher in the south of the country than in the north. This is mainly due to the delay in the iCCM scale-up process – some communes in several health districts have not implemented iCCM.  

In the first quarter of 2020, a total of 6,573 community outreach workers distributed between 40 health districts offered integrated community case management services and home- based treatment of malaria (HBTm). 

Challenges in addressing uncomplicated and severe malaria

  • Distance and road conditions: The distance to health centers negatively impacts care seeking. Most travel is by foot and it is not unusual for people to have to walk six hours for healthcare: 61% of the population is more than an hour’s walk from a health center (76% during the wet season, May–October). In the Tahoua region, settlements that are between 4–12 hours walk from a health facility during the dry season take even longer to reach during the wet season (12–24 hours).
     
  • Lack of household finances: June to October is a time for both peak malaria transmission time and acute malnutrition. During this ‘lean season’ – right before the harvest - subsistence farmers that make up the majority of Niger’s population do not have the economic resources to visit a health facility and the population is not aware that malaria drugs are available for free at health facilities.
     
  • Limited economic empowerment of women: Women who are primary caregivers do not go to the health facility unless their husband gives them the money. In addition, women are solely responsible for the health of children and do not receive support from male households.
     
  • Negative perceptions of health posts: Caregivers think the health post is understaffed and do not feel that they will receive the help they need. Other contributing factors to unfavorable views of health posts include restricted operating times, long wait times, lack of equipment and diagnostic capabilities, and lack of medicines.

Malaria epidemiological profile for Niger

Photo: Malaria epidemiological profile for Niger

Severe malaria admissions and deaths in Niger

Image: Severe malaria admissions and deaths in Niger
National treatment guidelines

Recommendation

Treatment

Strong

IV artesunate or artemether

Alternative

Quinine

 

Recommendation

Pre-referral

Peripheral health facilities

Rectal or parenteral artesunate or IM

quinine at the facility level

Community level

Rectal artesunate

 

Pregnancy

Recommendation

Treatment

For all trimesters

IV artesunate

Recommendation

Protection

IPTp

Sulfadoxine/pyrimethamine

 

 

Seasonal Malaria Chemoprevention

Recommendation

Protection

Children aged 3 months to 5 years

sulfadoxine-pyrimethamine and Amodiaquine (SP+AQ)

 

Sources of malaria financing for Niger

Image: Sources of malaria financing for Niger

Market Information

Injectable artesunate delivery in Niger
Arthemer delivery in Niger
Artesunate rectal capsules delivery in Niger