Nigeria

Photo: Alvaris Elvis from the Swiss Malaria Group

Malaria facts

Malaria is transmitted all over Nigeria; 76 % of the population live in high transmission areas while 24 % of the population live in low transmission areas.  The transmission season can last all year round in the south and is about 3 months or less in the northern part of the country.  The primary vector across most of the country is Anopheles (An.) gambiae s.s. [1]

According to the 2020 World Malaria Report, Nigeria had the highest number of global malaria cases (27 % of global malaria cases) in 2019 and accounted for the highest number of deaths (23 % of global malaria deaths). [2]

Case numbers increased 3.5% between 2016 and 2019,  from 293 to 303 per 1000 of the population at risk. Deaths fell 16%, however,  from 0.57 to 0.47 per 1000 of the population at risk during that same period. [2]

Microscopy data from the 2018 Nigeria Demographic and Health Survey (NDHS) show that the prevalence of malaria parasitaemia in children under five years of age is 23 percent (a decrease from 27% in 2015 and 42% in 2010), although there are significant regional, rural-urban, and socioeconomic differences [3]:

  • Prevalence ranges from 16% in the South and South East Zones to 34% in the North West Zone.
  • In rural populations, prevalence is 2.4 times that in urban populations (31% vs. 13%)
  • Compared to the highest socioeconomic group, prevalence among children in the lowest socioeconomic group is seven times higher (38% vs. 6%) [1]

The 2018 NDHS also indicated that 43% of the population slept under an insecticide-treated net (ITN) the previous night.[1]

The 2014–2020 National Malaria Strategic Plan (NMSP) expired in December 2020. However, the 2019 Malaria Program Review indicated that there will be no significant changes in the strategic direction of the malaria elimination program in the new strategic plan [1].

The Government of Nigeria has secured credits from three multilateral banks (the World Bank, African Development Bank, and Islamic Development Bank) totalling $364 million to fund health sector interventions in 13 states of the Federation for five years (2020–2024) for malaria [1].

Severe malaria case management and control

Under the strategic plan, the Government of Nigeria supports the treatment of severe malaria using injectable artesunate.[1] The country’s guidelines for Diagnosis and Treatment of Malaria (2015) recommend using injectable artesunate for the treatment of severe malaria, or intravenous quinine if injectable artesunate is not available. Both products are on the national essential medicines list and are readily available in country.[1]

The recommended pre-referral intervention for severe malaria is intramuscular artesunate or artesunate rectal capsules (ARC), intramuscular artemether or intramuscular quinine.[1]

Malaria in pregnancy

Nigeria has adopted the 2016 WHO antenatal care (ANC) model which recommends a minimum of eight contacts during pregnancy.

The proportion of pregnant women who received at least two doses of sulfadoxine-pyrimethamine (SP) more than doubled between 2013 and 2015 – from 17% to 41%. [1]There was a significant decrease in 2016 (31%), and then a return to 2015 levels in 2018 (i.e. 40% uptake of IPTp), A similar pattern was seen for the proportion of pregnant women who received at least three doses of SP, although coverage has not returned to 2015 levels (7% in 2013, 21% in 2015, 15% in 2016 and 17% in 2018). [2]

Factors hindering SP uptake among pregnant women include low antenatal care attendance rates, restrictions that prevent non-pharmacy workers from dispensing SP, missed opportunities during visits, and non-availability.[1]

The National Guidelines specify that pregnant women with severe malaria should be treated with injectable artesunate (or intravenous quinine, if injectable artesunate is not available) from the 2nd trimester of pregnancy [1]

Seasonal Malaria Chemoprevention

The National Malaria Elimination Program (NMEP) strategy recommends seasonal malaria chemoprevention (SMC) in nine states in the Sahel region: Sokoto, Kebbi, Zamfara, Bauchi, Katsina, Kano, Jigawa, Yobe, and Borno. The recommendation is for four doses of SP + amodiaquine [SPAQ] at monthly intervals over the 4-month malaria transmission season). There are 227 local government areas (LGAs) and a population of approximately 11 million children under the age of five years in these states.[1]

A total of 418,812,470 treatments of SPAQ will be required for SMC from 2020 - 2022 in the 9 eligible states to cover about 35 million children aged 3-59 months annually over the three-year interval. [1]

In 2018, only about 30% of the children eligible for SMC, received the intervention. The country intends to procure an additional 2.5 million SPAQ treatments to continue SMC efforts in Sokoto and Zamfara States.[1]

Healthcare tiers

The public health care system makes up 67% of all healthcare facilities and is divided into three levels: federal, state and local government areas (LGA) or National Primary Health Care Development Agency.[1]

  • The federal health budget covers tertiary care and disease control programs (including malaria control). There are 83 tertiary healthcare facilities.
  • The state health budget covers secondary care and there are 3,992 secondary facilities. 
  • The LGA budgets address primary healthcare while there are 30,098 primary healthcare facilities.

The government of Nigeria receives funds for malaria control from the Global Fund, USAID’s President’s Malaria Initiative and others. It has also secured loans from the World Bank, the African Development Bank, the Islamic Development Bank.  The country has similarly been funded by DFID (now called Foreign, Commonwealth & Development Office (FCDO) as well as a number of nongovernmental players. Private sector companies in the extraction industry have also implemented malaria control programmes.[1]

SMC programmes are being implemented in the Sokoto, Jigawa, Katsina and Zamfara States by the Malaria Consortium.[1]

Populations with low access to treatment 

North Eastern Nigeria: Due to insurgencies and attacks on health workers there are operational challenges for delivering malaria intervention services [4]

Rural communities: Some hard-to-reach rural communities (~5%) require special measures (boats or camels) to access. Routine service is difficult. [4]

Nomadic population: Population has no fixed location, making them hard to reach. They believe that fever is a Fulani illness that needs no cure; prefer private medicine vendors and avoid health facilities. [4]

 

Severe malaria policy and practice

National treatment guidelines
Recommendation Treatment
Strong IV artesunate
Alternative  IM artemether
Alternative IV quinine
Recommendation Pre-referral
Strong IM artesunate
Alternative Rectal artesunate (children)
Alternative IM artemether
Alternative IM quinine
Pregnancy
Recommendation Treatment
Strong Injectable artesunate